the kilowatt hours. i encourage the committee to think there renewable energy is artificially expensive and non- renewable is artificially cheap. one out of four children out of new your city has asthma. and magic of the environmental degradation. there is a tremendous price we are not factoring into carbon- based forms of fuel that is killing us and telling the resources we need to survive. last summer when gas prices were so expensive, people were screaming to, isn't it terrible. it is tough to live without gasoline but a lot harder to live without water, three days, that is it. i think you bring up a great point in terms of realizing the true cost of the exploitation of those kinds of resources. host: wisconsin on our independent line. caller: first, i want to thank you for c-span. i want to thank the two young people for being on the air. it is so important.

i don't remember if it was discovery, national geographic or the history channel but they showed a program where countries -- several countries in the world where they are playing with our weather and putting some kind of gas pump up into the ozone layer and it is affecting the way in that gulf stream patterns and other patterns, and it is influencing -- excuse me -- influencing our weather. and also, why can't governments all over the world outlaw plastic? it would create jobs and get rid of all of this crap all of our water? host of you address plastic -- but what about the issue of government controlling the weather or other efforts? guest: a lot of that is happening in china. i understand -- i think it is silver oxide that they are seeding the clouds with to

actually cause rain. the jury is out i think on how well the technology works. as far as i understand, it is pretty local as far as the impact. it does not really change weather on a large regional or certainly not a national scale. guest: you know, we have a lot of projects in the works around of projects in the works around the world to try to solutions to some of the problems that we have created, like seeding clouds were covering glaciers with an enormous part to prevent them from melting. -- with enormous tarps keep them from melting. but the best idea is prevention. that is something that, again, we all have a role. guest: isn't the singing, ounce of prevention is a pound of cure? host: road island, joe. caller: the real pollution is

not really coming from the people, but rather through the government and through the people from planet gren blew the mines. host: on that note, i will give you a chance to promote your show. starting when? guest: blue august is happening all month long. all august is a series of programming, intelligent intelligent and online. hopefully we can help to inspire people to think differently about the problems we're facing. and there are a couple of premieres next wednesday, a special with bob woodruff. guest: host: thanks for being with us this morning. >> and later this week you will hear from four mayors on how the economy is affecting their cities. tomorrow, the mayor of phoenix and then the youngstown, ohio

mayor on wednesday, and on friday it will be the mayor of fort myers, florida. it appears at 7:00 a.m. until 10:00 a.m. eastern every morning. the white house is holding a roundtable on health care. state and local officials and industry experts will also be present. the will be live coverage today at 2:00 p.m. eastern. >> president obama is wrapping the meetings with felipe calderon and stephen harper this morning. we will have live coverage from guadalajara starting at 12:30 p.m. eastern. >> this month, c-span2's with tv weekend with more stories on economy and history and

politics. tonight, these offers. -- these authors. >> tonight, on the agency's efforts to provide more transparency in to expand broadband. that is at 8:00 p.m. eastern on c-span2. >> by donations. >> federal or grants. >> honestly, i do not know. >> advertising? >> something from the government? >> 30 years ago, america's cable companies greeted c-span as a private business initiative, no government mandate or money. >> again, a joint press conference with the canadian prime minister and mexican president coming up live on c- span at 12:30 p.m. until then, "washington journal

." "taliban is now winning." this is the report from peter spiegel in washington. "the commander, general stanley mcchrystal, has offered a preview of the strategic assessment that he is going to deliver to washington later this month, saying that the troop shifts are designed to better protect the afghanistan civilians from rising levels of taliban violence and intimidation. the coming redeployments are the clearest manifestation on the death toll and spike in military deaths in afghanistan." we will look at that chart this morning, the mounting toll of the u.s. troop casualties in

afghanistan. another article this morning from the philadelphia -- "philadelphia inquirer." de "the president's national security adviser did not rule out adding more u.s. forces in afghanistan to help turn around a war that he said yesterday was now -- was not now in crisis. james jones said the united states would know by the end of next year whether the revamped war plan obama announced in march was taking hold, with new benchmarks that reflected a redrawn strategy. the outline is expected next month." on the weekend talk shows, jones did little to dispel the rolling expectation that obama soon will be asked to supplement the 21,000 additional troops already approved for afghanistan this year."

we will speak more in the program with congressman sherman about afghanistan. your chance to weigh in his right now. jeff, good morning. caller: thank you for taking my call. i believe that the obama administration is doing the right job by making the focus of afghanistan -- i want a president who believe we never should have been in iraq in the first place and that the real problem is the radical extremism in afghanistan and pakistan. host: how you think that the administration has done so far with the situation in pakistan as it relates to efforts in afghanistan?

caller: it is hard to deal with the situation in pakistan given that you are dealing with a government that is supposedly supportive of the u.s.. they can only do so much without pakistani government approval. but i truly believe that some of the extremism is in pakistan and they have to be dealt with as well. host: thank you for the call. j., north carolina. good morning. caller: thank you for taking my call. you had a guest yesterday on c- span, michael shuer, he some of the situation in afghanistan perfectly as far as i am concerned. that this will always be a tribal society. that the government is completely corrupted by the drug trade in that afghanistan is not

worth of american life. it is not called the graveyard of empires for nothing. i think that the best thing that we can do is get out. i do not see us changing anything. i do not care if you put half a million troops there. i do not think anything would change. host: what do you think of what the president has already authorized? 21,000 more, this assessment is set for september. what if the assessment says that we need more troops? >> i'm sure that it will. all that you are sending over is 21,000 bull's-eyes. you are never going to defeat any kind of radical army like the taliban unless you send over 1 million troops and pursued them night and day, which we are not willing to do. host: thank you for the call.

washington, d.c., independent line. welcome. caller: good morning. this war, the afghanistan war, it should never have happened. we know that september 11 the al qaeda people started a waging war. we should have systematically eliminated the people that attack us. there was never a single afghan war before september 11. host: much was made, remember, in the 2008 campaign that we took our eye off of the ball of afghanistan and that now that we are refocusing on that you are saying it should not be our focus point. caller: it should be, but it

should be against al qaeda. the afghani people are nomadic. i have come here to america to raise my children. when i see these young americans being killed, it just bothers me. host: when did you come to the u.s.? caller: 24 years ago. host: thank you for the call. here is a picture of a marine from "the new york times." the headline is "drug chieftains tied to taliban. generals assert legality, a list of 50 to be caught or killed. 50 afghans believed to be drug traffickers with ties to the taliban have been placed on a pentagon target list to be captured or killed, reflecting a major shift in american counter

narcotics strategy in afghanistan, according to a congressional study to be released this week. united states military commanders have told congress that they are convinced that the policy is legal under the military rules of engagement and international law. they also said that the move is an essential part of the new plan to disrupt the flow of drug money that is helping finance the taliban insurgency." what is next? that is our question this morning. next caller, good morning. caller: good morning. thank you for c-span. i have been taking classes in middle eastern studies. both what is normally considered the middle east and the greater middle east, which afghanistan is a part of. host: where are you going to school? caller: i am out of school but i am a teacher and through our program we have different ones,

one of them is middle eastern studies. i will make a flood, i am going to school at george mason, that is where the program is that. what it has shown is that afghanistan is a country that should not be a country. it was created by pakistan by the british. pakistan used to be two different countries but they split apart because the ethnic majorities could not get along. afghanistan is made up of many to from parts -- many different parts of ethnic tribes. forming them into one country is impossible. i do not think that america can win because it is a guerrilla war in a mountainous region. i do not know what we are spending our money on. it feels like iraq again.

we are fighting to win and get victory for something where we do not know what that will mean. host: are you a history or political science teacher? @@@@ gueswhen i taught in prince wilm county there was a large afghan committee down there who are refugees from afghanistan. host: how many languages do you speak? caller: four different ones -- english, spanish, and i'm learning arabic, and i have chinese. host: will go to michigan with trawls on the independent line. -- with charles. caller: yes, afghanistan could easily turn into another iraq.

the lessons we have learned their, we should carrythere, -- there, we should carry them over. too much is being used from the ridiculous bush cheney policy. host: when you say leftovers, do you mean military leaders? caller: people in the pentagon, guess. as far as the drug problem, a number of countries in the world are using, as a replacement for morphine in the spectrum of pain medication, they are using heroin. host: here is a quitter. "the saddest part of the entire war is the fact that we never had any substantial evidence linking bin laden to 9/11 -- and

for what"? michael, fort lauderdale. good morning. caller: my comment on afghanistan is a lot like what we have heard other callers say. it seems that this is an area of the world that is completely undeveloped, nothing really there. hardly anyone has any education. it would take decades to make any real difference in that part of the world, if we ever really could. and i really think that our military did a phenomenal job in iraq. they never got the credit. it was a debilitating thing to fight urban combat. if you go back and look at instances of the second world war, where they had no rules at all, it was demoralizing for soldiers to fight in an urban

combat zone. we did this brilliantly in the wrath, but it is not the case in afghanistan. different typography, with the chinese and the russians putting all kinds of sickness in there, like we were doing when the russians were in afghanistan. host: what is the best case scenario? what is going to make us say that we can leave? caller: there will not be an instance where we can say that. i am not downgrading the military, they are an excellent fighting force, but there is no place that can hold it down. if you look at history, it is replete with military units that have entered afghanistan and have never been able to make a substantial difference. the gang is con was chopping

people's heads off, no care what ever for the local population, and even they had a hard time controlling afghanistan. how will we do it? especially with all of these rules of engagement. if we keep a limited number there, keeping things under control, that might be the only way where we could really make some kind of stability. we tried replacement crops in colombia and other places where they were growing drugs. we asked them to grow different crops, you just cannot drive that out. someone who has been growing poppies for centuries, you cannot get them to grow squash. you cannot bring about a cultural shift like that in a very short period of time. host: 50 more minutes for your calls on the next step in -- 15

more minutes for your next calls on afghanistan. "since the invasion of afghanistan eight years ago, the u.s. has spent $223 billion on war-related funding for that country. aid expansion pitchers -- aid expenditures, excluding the costs of combat operations, have grown exponentially." david, democratic line. caller: i would like to comment a bit on the situation in afghanistan. it in the first place, we are worried about helping in the united states? why not stop the two wars? we would then not have to worry about the money that we would have for paying for this and that. this war is politically motivated. there should be no war anywhere.

host: define that. caller: i will love. in the first place, we should not have any troops in foreign countries killing people. we are going over there with soldiers to kill. and russia fought their little war -- killed. russia fought their little war. there is no reason to be in afghanistan or iraq. you have got a new president, take us out of there. this is just doubletalk. host: we started talking about the comments yesterday with jim jones. here is what he had to say about afghanistan. caller: we are turning the

responsibility for their security and economic prosperity over to afghanistan as quickly as possible. we are doing that in three ways. one, the wren ounce comprehensive strategy -- so, the one new comprehensive strategy, this economic development with good governance of law for local mayors through cobble. we generally have done pretty well over time on the security front. nato, the united states, 47 sovereign countries on the ground in afghanistan. the un, the world bank, all kinds of non-governmental organizations, all of them turning in the right direction. that is the new strategy. host: our question for you is

what is the next step in afghanistan? this is a twitter, "afghanistan will grow as the infrastructure rows, like any war ravaged land." independent, new york city. welcome. caller: like the other person, i do not think that this is a war that we can win. we have spent too much money over there. we should get out as soon as possible. you will not know if you have one or not anyways? who are you talking to? people are just getting killed. host: another call from new york. you are on the air. go ahead. caller: the big problem that everyone should focus on is the fact that the american people are smart and want certain

things, but our politicians do not care. that is the thing. the reason is because they all get so much money, they do not care what we want. they talk about health care, they are always talking about the problems with canada and massachusetts. they do not look at the other countries that have a wonderful health care. that is because there is too much money against the kind of health care that we need. until we see this, putting the republican democrat argument that goes on and on, people getting wrapped up in real life , there are politicians that do not what we want any more. host: the president is going to get a report from general mcchrystal and others. you talk a lot about politics here, what are his options, politically?

is he listening to the people, the voters and citizens? caller: know. people do not want to be in afghanistan. they want the money for our country. as long as you have all of these big halliburton and other people that are making millions of dollars off of these wars with equipment and private mercenaries in all of that. we will never get out. the money is ruling. until we have clean elections where the politicians are not on the take, we will not get what we want. we will only get what big money once. host: jason, charlottesville. good morning. karly caller: that was a great comment from the last caller. looking at afghanistan strategically, the primary

reason that we are there, there is a now-defunct oil company their that pays and employed to the former president of iran. there was a pipeline built that went to the arabian sea. the taliban is no longer in control. hamid karzai is no longer president. host: is he not still the president? caller: i am not sure. there was election. host: the election is in 10 days. caller: than i am getting ahead of myself. regardless, all of these places are located right around the pipeline being built to export

oil to the arabian sea. thank you a lot. i encourage everyone to read investigative journalism. host: where is he right? caller: a lot of books, lots of english papers and on the bbc. you will not find his work much in the united states anymore. host: thank you, jason. a couple of headlines, this one is on iraq. "report sees recipe for civil war in iraq." "a report to be published this month by the u.s. government's prestigious national defense university warns that the iraqi army and police are becoming the pawns of sectarian political parties, a trend that they call a recipe for civil war.

" we have a different story from "the baltimore sun this morning -- the baltimore sun" this morning. "a narrow probe is a legend for the abuse of terror suspects." only available in a few papers, "eric holder is about to appoint a kremlin -- criminal prosecutor to investigate alleged did cia abuses committed during the interrogation of terrorism suspects. a senior justice department official said that holder envisions a probe that would be narrow in scope, focusing on whether people went beyond techniques that were authorized." here is bethesda, md., a marine on the line. good morning. caller: good morning. how are you doing?

i just came from afghanistan. i am an injured marine with echo company 28. i think that the marine corps is doing an excellent job. we have helped to secure a lot of the southern regions, helping to push out the taliban. in the terms of providing security, it is so that they can open their markets and have housing and to do farming without threats. host: do you think that we need more troops and others on the ground? caller: i think that the more, the better. a lot of my friends have been hurt. the first person that was killed was lance corporal sharp.

recently, lance corporal lasher was killed. that is just a few. host: those were a couple of your buddies? caller: yes, sir. very close to me. host: sorry to hear about that. can you tell us the nature of your injuries? caller: i took shrapnel to my eye. a lot of my other friends here in bethesda, md., have been getting excellent care from all of the people here. we are very grateful. host: are you going to be able to see ok? caller: i had an excellent prognosis. right now i can see good out of my right eye. host: what is your home town? caller: oakland, california. my base is in north carolina, the company to eight.

-- 28. host: thank you for calling. don, michigan. caller: nancy pelosi in 2006, nothing has happened and that is what is so upsetting. to the corporal, i would like to thank him. why do you think that they have not started a draft? they know that the purple push would be on. watch out for that military complex. we should note, he was the commander of allied forces. i do not see them out there protesting, but thank-you to c-

span. host: headline in the state newspaper from south carolina, headline complaining about mark sanford, "governor mark sanford used state money in state aircraft for personal and political trips, often bringing along his wife and children, contrary to state law, on official use, according to the associated press. since he took office in 2003, he has taken trips on state aircraft, dentist appointments, and a birthday party for a campaign donor. north carolina, renee. hello. caller: i would like to say, concerning afghanistan, i come from a military background -- i

was raised in fort bragg, north carolina. we are freedom fighters in this country. we are here to help the people of afghanistan. when it comes to the taliban and al qaeda, they want us dead. they do not care about anything but seeing as dead. i wish that more people would stand up and support our military instead of putting us down. we are not fighting over oil, that is ridiculous. host: a couple more media stories, the publisher says that "the demise of the rival

paper was no guarantee that this newspaper would make it. in an article in march, seattle was said to be becoming a "one newspaper town." on a month-to-month basis, we are starting to operate in the black. " for folks going back to school, textbooks are going on line, offer for ipod and iphone, allowing students to access 7000 titles. new jersey, good morning.

caller: thank you for having me. this is a great place for foreign and debate. we have to work with the world leaders of the world. the un has that job. if there is a large tribal area, men of good conscious have to develop education to bring peace. the u.n., this is what they are supposed to do. american caller: our men are dying out there because the rest of the world is not helping this area to develop. >> alive picture from

guadalajara, mexico -- a live picture there. in just a few moments president obama will meet with the paramounprime minister of canadl as the president of mexico. they're about trade, immigration, border security. they will talk about the h1n1 virus, climate change, and many other issues. until then, more of your phone calls. not merely to represent -- misrepresent that insurance reform legislation but to disrupt public meetings and prevent members of congress and

constituents from conducting a civil dialogue. these tactics -- tactics have included hanging in effigy one democratic member of congress and maryland and protesters holding a sign displaying a tombstone. saying, just say no. vitter op ed continues -- these disruptions are occurring because opponents are afraid not just of differing views but of the facts themselves. the drowning out opposing views is simply on a very -- un- american. drowning out the fact is how we failed on this task for decades. the first fact is, health insurance reform will be more patient choice. opinions of speaker pelosi and for the majority leader steny hoyer writing in today's "usa today." do you think these disturbances are american? the words of the speaker and majority leader. if you agree, the number to call is --

additionally, in "usa today" i have an op-ed piece on the same topic. >> the president is continuing his summit with stephen harper and felipe calderon. let's listen. >> the leader for north america shares addition. we are the only other regional committee that is safe and secure. in an age marked by globalization the challenges can only be overcome jointly. thus, the importance of keeping the dialogue and trust and

cooperation alive among our three countries. we have reiterated that the values are part of which our communities are founded on, democracy, freedom, justice, and the respect of human rights. our three nations have reiterated our decision to combat and struggle against organized crime to bring more security to our communities. the struggles we have led it in mexico for the rule of law and the security of our mexican people forces us to stop the traffic of weapons and money. the notions of responsibility, accountability, the exchange of information, and the building up of institution should be the guidelines for cooperation.

in this context, the three states that make up north america have to take the leadership and foster the necessary measures to recover our economic growth. in our past we have had to implement counter-cyclical measures in our three countries. we can stabilize our economy and a coordinated way and bring about trustworthiness and uncertainty. it is also necessary to build our financial institutions such as the world fund, the international monetary fund which are fundamental to guarantee the financial resources. in the case of latin america, the support the will of enable

us to recapitalize development will be the best action in regard to commitment to the poor countries in the region. i am certain that at the next g- 20 meeting notes take place in pittsburg, in the united states -- at the next meeting, we will reorganize to reform these organizations that are key in the recovery of our economy. i think president obama for fostering the meeting in pittsburgh, and likewise all three of our nations have to restart our agreements. we recognize it is essential to abide by nafta and resolve the pending topics that impede us to reach greater regional competitiveness, and it is

important to see how we will fulfill our commitments and regard to the environment and in regard to our labour domains with regard to trade agreement. i am convinced that only by having advantages offered by our cooperation shall we be successful in the world that is ferociously competing. at this summit we have reached important agreements such as boosting the standardization of the regulations and certification some of our products, as well as procedures and sanitary procedures that can be simplified yet increasing without losses. that can increase the economic competitiveness. the objective is to have secure and efficient conditions.

these procedures will be implemented with no bureaucratic or card fetched red tape -- or far-fetched red tape in our offices. this will decrease surprises for food and improve competitiveness of our economies. on the other hand, on the bilateral aspects, mexico and the u.s. will launch modernization of initiatives at our common borders with determine terms to promote the regional competitiveness actions. mexico is pleased to say we will integrate the first international bridge that is currently being built after so many years between the u.s. and mexico. all three have coincided in the importance to face the

repercussions of climactic change. the cost is high, but we will pay for lack of actions -- that cannot be calculated. we have to foster the global agreements in copenhagen and the instrumentation for a green fund that will support actions in regard to the global scale of climactic change. we need to make progress in regard to clean energies and technologies as well as the development of our carbon market in order to have regional market. north america must be recognized as a responsible region and must set the example for the world in terms of environmental cooperation amidst countries with different levels of development. cooperation must prevail at all moments. thus, it was demonstrated last april when our three

countries faced h1n1. working together week showed our highest expressions of responsibility, accountability, and trim spending of because we alerted other regions in the hemisphere they also have the opportunity to implement preventative measures to abate the propagation of the virus and avoid its repercussions. thirdh1n1 as we know it will be back this winter. we are getting prepared to face it to and responsible manner. we want to update its impact for our people. first, minister, mr. president, ladies and gentlemen, at this summit the representatives of the u.s., canada, and mexico have had an open industry dialogue as countries that share

values that work to consolidate the right conditions for development. and they have been able to found a successful society based on brotherly and responsible relationships. we believe in north america that is a united and prosperous, that it is able to build a better future for the forthcoming generations. i want to give the floor now to mr. stephen harper, prime minister for canada. [speaking french] [been translated into spanish] [still speaking in french]

on the north american economy and the global one, [speaking in french without translation]

[speaking in french without translation] speaking about the trafficking of drugs in referring to what felipe calderon has said. he says it is important to affirm the rule of law. he is talking about the integration of the three economies.

[speaking in french] he says all three countries stick to be good friends. -- seek to be good friends. just once again, thanks to president felipe calderon and thanks to the mexican people for their hospitality, and thanks also to president obama for r frank discussions. those discussions fit into three broad categories, the economy, north american health and

secured, and energy, environment, and climate change. on to the economy because of canada's strong record of financial regulation and fiscal management, we provided an informed voice at these meetings. as we approached the g-20 summit in pittsburgh we continue to emphasize the country's most strengthen financial regulations and institutions, continue to implement timely stimulus, and maintain open markets to resist protectionism. on north american health and security we talked about our shared an effective response thus far to h1n1. it is a cross border threat to us all. the excellent cooperation among these three countries was effective in helping to manage the initial outbreak in we will continue our cooperative efforts. on security canada recognizes the courageous commitment of president felipe calderon and taking on drug-traffickers. we support these efforts as it

is a shared challenge for us all in north america. on international peace and secure become a canada supports ongoing o.a.s. to find a peaceful resolution for the conflict in honduras. we need to restore the rule of law and democratic governance. i missed energy and climate change -- given the integrated nature of our economies we did talk at some length about the importance of working together on a north american approach to climate change. and also on doing our best to ensure that out of copenhagen and going forward we will reach an effective and genuinely international new world protocol on greenhouse gas emissions. to conclude, canada, the u.s., and mexico are good neighbors and friends and the sovran neighbors where but independent and enter-japan and. i look for to seeing both

presidents at the g-20 and look for to hosting both next year at can of this summit. -- at the summit ain canada. >> good morning, and buenos dias. i want to thank my great friend, president felipe calderon for his hospitality, and for hosting us at this important segment, as was my good friend, prime minister stephen harper, and i want to thank the people of guadalajara, mexico for the incredible warmth they have shown us. this is my second trip to mexico as president. here in mexico the worlword is -

and in canada it is ensemble -- but today we come here together matter how you say. we look for the opportunities that we will face together. the city could not be a more fitting venue. here in guadalajara precede all the richness of mexico's heritage. its arts, architecture, vitality, and culture, and we also see all the possibilities of mexico's future. the innovation, high-tech industries, and entrepreneurship that makes this one of our hemisphere's most dynamic cities. we are coming together here as canadians, americans, mexicans, as business partners, educators, each bringing their unique traditions and bound by mutual respect you and the 21st century north america is the fine not simply by borders, but buy our bonds. that is the spirit that defines

the productive summit we have had here today. first we agreed that we must work together to restore our common prosperity. the global recession has cost jobs and hurt families from toronto to toledo to tijuana. we renewed our commitment to work together in all three capitals and building on our progress from the previous summits we agree to take coordinated action to restore economic growth and create jobs, including workers in the auto industry in north america. because so much of our common prosperity in millions of jobs depend on trade that flows across our borders, billions of dollars worth of trade every day, we reaffirm the need to reject protectionism. we reaffirm commitment to common sense regulations and intellectual property rights. we are among each other's largest trading partners. as we work together toward

lasting prospered we need to expand that. i would note that our common prosperity also depends on orderly, legal migration. all three countries have been enriched by our ties to family and community. i think of my own brother-in-law who is canadian. i think of the many mexican- americans from jalisco who found homes and taxes and in my hometown of chicago. at the same time, altering nationalities expect their borders to be safe and secure. that is why my administration will continue to work to fix america's broken immigration system in a way in keeping with our traditions of being both a nation of laws and of immigrants. because of our future prosperity depending on clean energy economies rebuild on bilateral efforts to root invest in the energy and jobs. we commit to those measures announced in italy last month. we will take the lead in

reducing emissions by 80% by 2015 and work with other nations to cut global emissions in half. indeed we made progress toward the concrete goals that will be negotiated at the copenhagen summit in december. i want to commend mexico for its leadership in curbing greenhouse gas emissions. and to think president felipe calderon for his innovative proposals. -- to thank him. second, we reiterated our abiding commitment to the city of our people. in response to the pandemic, our three governments have worked closely with the science as our guide and we resolve to continue to take all necessary preparations and precautions to prepare for the upcoming flu is in and protect health. we also resolved to continue confronting the threats from the

drug cartels who cause a much violence and death in our countries. on many occasions i have said that i heartily commend president felipe calderon and his government for the determination and courage to take on these cartels. and the president reaffirmed his commitment to transparency, accountability, and human-rights as they waged this difficult but necessary 5. the u.s. will remain a full partner in this effort. we will work to make sure that mexico has the support it needs. the u.s. will also meet its responsibilities by continuing our efforts to reduce the demand for drugs and continuing to strengthen the security of our shared border, not only to protect americans, but to stem the illegal southbound flow of cash and guns to help fuel this extraordinary violence. third, we reaffirmed our abiding commitment to common deli's including peace, democracy, and human rights. we discussed of the coup in

honduras as has been mentioned. all three nations are united on this. the democratically-elected president remains for the sake of the honduran people. democratic and constitutional order must be restored. we will work with others, especially the o.a.s. to achieve a peaceful solution. we pledged to continue these efforts. i look forward to welcoming prime minister stephen harper to washington this fall into welcoming both at the g-20 summit in pittsburgh were have to reciprocate the hospitality of president felipe calderon. our purpose today is a reminder that no nation can meet that challenges of the time on our own. common aspirations can only be achieved working together. that is what the nearly half a billion people in north america expect from us and that is what we will do. thank you.

>> [speaking in spanish] >> good afternoon. there are certain questions about the violation of human rights here in mexico and all these problems, fighting drug trafficking, so are you going to certify mexico? how can we move forward with the initiative? we are also concerned about any attempt against felipe calderon's lfie. we know about certain threats and insecurity that prevails. this is certainly related to your country. we are concerned about the visa problem, too. but comments would you have?

>> it sounded like a very good question. go ahead? >> [asking in spanish] what are your concerns regarding this? we would also like to know if mexico will be certified? and if you help? if you will help to apply resources for the initiative? we have also heard about some attempts against the life of president felipe calderon -- do you have any knowledge of this? we're also concerned about national security and visas. we would like to know if there is any possibility that you might turn this around, that we may not have any limits on visas? .

. >> a set of drug cartels that not only result in extraordinary violence to the people of mexico, but also undermining institutions like the police and the judiciary system that, unless stopped, would be very damaging to the country. with respect to conduct of this battle against the cartels, i have great confidence in president calderon's administration applying the law

enforcement techniques that are necessary to curb the power of the cartels but doing so in a way that is consistent with human rights. we discussed this in our bilateral meeting. i am confident that as the national police are trained, as the coordination between the military and local police officials is improved, there is going to be increased transparency and accountability, and human rights will be observed. the biggest, by far, violators of human rights right now are in the cartel's themselves that are kidnapping people and extorting people and encouraging corruption in these regions. that is what needs to be stopped and that is what president calderon is committed to doing, and what i'm committed to helping president tell the route accomplish as long as he is president of mexico. >> we will continue.

>> on the question of visas, it is important to understand the position is due to one thing and one thing only, so dramatic price we have seen over the last few years and this year in particular in the number of bogus refugee claims being made from mexico into canada. it is important to understand that the decision has nothing to do with the actions of the mexican government. the mexican government has cooperated with us in efforts to stem this particular problem, to limit this particular problem, the attorneys to work with us in ways that we might reverse it. but the underlying problem, as i have said to president called the run and others, it is in the canadian refugee laws. it is far too easy in canada to make a boat is ready to claim as a way of entering the country.

we have to change that. it is unfair to those who are legitimate refugees and also unfair to the hundreds of thousands of people who are working through our immigration system to become immigrants to our country. as i say, we will continue to work with mexican authorities to try to limit this problem, but in the absence of legislative change, it is very difficult for governments to control this other than through the position. is the only tool available to us right now. we need additional tools from our parliament to stem the flow of bogus refugee claimants and have additional tools to deal with this kind of problem. >> alex panetta, a canadian press. >> let me address these three

topics which are very important to us. first of all, my government has an absolute and categorical commitment with human-rights. the struggle, the battle we are fighting against organized crime, is precisely to preserve the human rights of the mexican people -- right to safety and security, personal safety and integrity, and the right to have a safe family, the right to work without being really molested or perturbed in the struggle for security, the safety of the mexican people. obviously, we have a strong commitment to protecting human rights of everybody -- the victims and even the criminals themselves. this is how it has been and how it will continue to be, and this is how the federal police will act, the attorney general's and armed forces will act. in all of these cases, there have been a very scrupulous effort to try to protect human

rights, in all cases. and anyone who says the contrary certainly would have to prove this. any case, just one case where the proper authority has not acted in a correct way that the competent authorities have not punished anyone who has abused their authority, be they police officers or soldiers or anyone else. we have a clear commitment with human rights, we have met this commitment, and we'll continue to do so. not because of money that might come through the merida initiative or 1 cent at the u.s. congress, because we have a strong commitment to a human rights, and i come in a personal sense, for several decades now, have always had this commitment. i have details about what you have pointed out. in any case, it will not be the

first or last occasion on which the -- we might hear something about an attempt against my personal -- about my life, my person. but once again, the government just cannot stop -- we know that we are destroying the criminal organization. we are hitting them hard, hit in the heart of the organization's, making them back away. they know we are not only taking an initiative in the struggle against crime, but we are actually being able to protect and defend our country better as time goes by. this is not a type of a vengeance, of getting back at anyone. we want to make sure that mexico is a safe place to live in, that we will not be able to move forward in this. we are not just talking about this organization, but the basic

objective is to provide security, safety for the mexican people. this is something the mexican people are entitled to. their family, their children can go out into the streets and play, can go to school, can make progress and to fulfill their aspirations that mexico be a free country, free of delinquency, free of violence, that mexico be a safe country. and in this struggle, we will not be intimidated, nor will they put a stop to our efforts. once again, i certainly hope that mexican society recognizes that all of the efforts that we're making along these lines -- the police force who have been victims of a tense and toward the acts by the criminals -- attempts and the, the acts by the criminals, different attorney general's offices -- we are committed to this ideal of having a set mexico unsafe country. these are values that we believe

in, and it is stronger than any threat whatsoever. once again, we've had a dialogue with prime minister harbor on several occasions, as we do on this occasion, about the summit, and a matter of visas for mexican visitors. we have talked and -- we have talked openly and frankly. certainly, mexico feels very bad about this decision, about this rejection, even though it is a privilege of the canadian government to stipulate this. but it certainly gets in the way of a good relationship of what prime minister harbor and i are doing. and the explanations that prime minister harper has mentioned -- there is a problem with the bogus with fiji claim problem, and this has led to an abuse of the system, and we are trying to

do away with the underlying causes of the abuse regarding the system for receiving refugees in canada. once again, for me, it is very clear that as the president of mexico, i certainly have the application ensuring that a specific talk on the bilateral agenda not deter reaching our full potential of other matters on the agenda, and once again, here lies a great opportunity in this particular area of economic -- of the three countries' economies. and this will take our whole region up to a higher state of competitiveness, the benefit of our people. these are the lines we've been working along. we have been making great strides in this sense. we certainly will continue to work along these lines. >> let me provinces by saying we

only get one question each. -- preface this by saying that we only get one question each -- it is actually a two-it is for the three leaders, primarily for president obama. i would appreciate it if the prime minister good answer in french as well. buy american has caused considerable concern outside the united states. i'm wondering what you discussed about buy american in this meeting. on and not completely related topic, health care has been at issue a tremendous debate in the country, and canadians have looked on with some fascination, as our health care system has become a political football in your country. i like to ask the prime minister harper and president obama whether there are elements of the canadian health system,

particularly the public model, which are worth emulating. >> first of all, with respect to the buy american provisions, i want to assure you that your prime minister raises this with me every time we see each other. that is important to note, that he is expressing his countries concerns. i think it is also important to keep it in perspective that in fact, we have not seen a sweeping step towards protectionism. there was a particular provision that was in our stimulus package that did not extend beyond that. it was wto-compliant. it was not something that i thought was necessary, but it was introduced at a time when we had a very severe economic situation, and it was important for us to act quickly and not

get bogged down in debates around this particular provision. prime minister harper and i have discussed this and there may be mechanisms whereby states and local jurisdictions can work with provinces to allow for cross border procurement practices that expand the trading relationship. but i do think that it is important to keep this in perspective. this is no way -- this has no way in danger billions of dollars of trade taking place between our countries, and it is not a general provision, but was restricted to a very particular aspect of our recovery package. with respect to the health-care debate, we are having a vigorous debate in the united states, and i think that is a healthy thing. the reason is necessary is because we are on a currently unsustainable path.

we spend far more per person on health care than any nation on earth. our outcomes in terms of various measures of well-being don't bring us at the top. we are not doing better than a lot of other advanced, developed countries that are spending much less per person. individual families are being bankrupted because of the lack of insurance. we have got 46 million, up 47 million people without health insurance in our country. for those who do have health insurance, they are always at risk of private insurers in the meeting their insurance because of a pre-existing condition, -- eliminating their insurance because of a pre-existing condition, or because they lose a job or change jobs. the final aspect of it is that health-care inflation is going up so rapidly that our federal budget simply cannot sustain, or

can businesses that are increasingly having to make decisions, whether they hire more workers or health care, or stop providing coverage or force more costs on to their workers. the whole system is not working well. there are going to be a lot of opinions, and congress has moved forward and we are closer to achieving a serious health reform package that we have been in the last 40 to 50 years. but there is a continuously of vigorous debate. i've said that the canadian model works for canada and would not work for the united states, simply because we have evolved differently. an employer-based system and a private-based health-care system stands side by side with medicare and medicaid and our veterans and ministration health care system. we have got to develop a

uniquely american approach to this problem. this, but white, is a problem the -- this, by the way, is a problem that all countries will have to deal with at some local, because of medical inflation continues, everybody's budgets will be under severe constraints. we have to make sure that we have a sensible plan that provides coverage for everybody and continues the role of the private marketplace, provides people who do not have health insurance for graaff fall into the cracks in the private marketplace a realistic and meaningful option. we have yet to do it in a way that changes the delivery system so we are not engaging in the wasteful, inefficient medical spending that is so costly to us. i suspect that we are going to have continual, a vigorous debate. i suspect that you canadians will continue to get dragged in by those who oppose reform, even though i have said nothing about canadian health care reform.

i don't find canadians particularly scary, but i guess some of the opponents of reform think that they make good boogie man. i think that is a mistake. i suspect that once we get into the fall and people look at the actual legislation that is being proposed, more sensible and recent -- more sensible and reasoned arguments will merge amonand we will get this passede sar to takes along with the question. -- get this passed. sorry to take so long with the question. >> [sppeaking french]

on buy american, we did have a good discussion, as president obama said. i'm happy to see that the provinces and the federal government have come to an agreement to work collectively on this matter, which is largely within their jurisdiction, since this concerns national procurement. our respective trade ministers have been talking, officials are talking, and we anticipate the

president and i will be discussing this at great length in our upcoming meeting street on the american health care debate, the debate over the system of health care, as we know, as you know well, canadians support their own health care system. as for the rest of the question, my only answer is that this is an american debate, and the responsibility of the provinces. >> ginger thompson, "new york times." >> i would like to start with president obama. given the fight that you are having to wage for health care, i wonder if you can tell us what you think the prospects are for immigration reform, comprehensive immigration reform, which he said is your goal, and whether you think that the blows you are taking now on

health care, and that the democrats are likely to take around the midterm elections, will make it hard if not impossible to achieve comprehensive immigration reform in this term, and what you have told president calle calderon about that. president calderon, i would like to hear your thoughts on honduras. there are some who have said that the united states has not acted strongly enough to return president saliva -- president zelaya to power. i am wondering what could be done to restore democratic order to on their race. prime minister -- democratic order to honduras. a few months ago, the homeland security secretary of aggravated canadian sensibilities when she compared the canadian border to the mexican border. i wonder what you think about

that, and how you feel about the united states using some of the enforcement strategies adopted on the southern border in the north. thank you. >> that is all? [laughter] >> that is all, mr. president. >> first of all, ginger, i don't know if you are doing prognosticating about the outcome of the midterm elections, which are over a year away. i anticipate we will do just fine. and i think when all is said on health care reform, the american people will be glad that we acted to change an unsustainable system so that more people have coverage, we are bending the cost curve, and we're getting insurance reforms of the people don't get dropped because of pre-existing conditions or other issues.

understand, though, that i am not acting based on short-term political calculations. i am looking at what is best for the country long term. if i had been making short-term political calculations, i would not be standing here as preston, because nobody calculated that i could win the presidency. with respect to immigration reform, i continue to believe that is also in the long-term interest of the united states. we never broken immigration system, nobody denies it -- we have a broken immigration system, nobody denies it, and if we continue on the path we are on, we will continue to have tensions with our mexican neighbors, people crossing the borders in a way that is dangerous for them, unfair for those who are applying legally to emigrate, and we are going to continue to have employers who are exploiting workers because they are not within a legal system. and so often times they are

receiving less than minimum wage or don't have overtime work are being abused in another fashion. that is going to depress u.s. wages. is causing ongoing tensions in side the united states. it's not fair and it is not right and we will change it. now, i have a lot on my plate, at 8 is very important for us to seek -- and it is very important for us to sequence these initiatives so that they do not just crash at the same time. will we have said is that in the fall, when we come back, we will complete health care reform. we still have to act on energy legislation that has passed the house but the senate, i am sure, will have its own ideas about how it wants to approach it. we still have financial regulatory reform that has to get done, because we do not want a situation in which irresponsible actions in the global financial markets and precipitate another crisis.

that is a big stack of bills. fortunately, what we've been able to do is begin meeting with democrats and republicans and the house and senate -- secretary to paul econo -- secretary napolitano is coordinating the discussions. i anticipate that before the year is out, we will have draft legislation and sponsors in the house and senate ready to move this forward, and next year, we should be ready to start acting. and i going to be built this that my fingers and get this done? no. this will be difficult, it will acquire a bipartisan cooperation. there will be demagogues out there who tried to suggest that any form of pathway for legalization for those in the united states is unacceptable. those are five that i have -- fights that i have to have won

the poll numbers are at seven or zero when my poll numbers are at 40. -- fights that i have to have when my poll numbers are at 70 or when my poll numbers are at 40. we can create a situation where we have border security, an orderly process for people to come in, but also giving an opportunity for those in the united states to be able to achieve a proper way to citizenship so that there don't have to live in the shadows and the children and grandchildren can have a full participation in the united states. i am confident we can get it done. excuse me, i know this was not directed me, but i want to make one quick point on honduras, because he repeated something that -- you repeated something that i've heard before. the same critics who say that the united states has not

intervened enough in honduras are the same people who say that we are always intervening and the yankees need to get out of latin america. you cannot have it both ways. we have been very clear in our belief that c-span.opresident za was removed from office illegally, it was a coup, and he should return. we've cooperated with all international bodies in sending that message. if these critics think that it is appropriate for us to suddenly act in ways that, in every other context, they consider inappropriate, then i think what that indicates is that maybe there is some hypocrisy involved in their approach to u.s.-latin american

relations that that is certainly not going to guide my administration's policies. >> many of the people who worked in the united states, who live in the shadow, come from -- these are people who have migrated in order to build a better future for their families. all of them, or most of them, have enormously contributed to the american society, the american economy, and it is unthinkable to see it that the u.s., the main american power of the world without the contribution of the mexican

workers, laborers. this is not only of good will statement. during our meeting, we handed the delegations the benefits of north american and mexican population representing in terms of the total population in the u.s. the only way to have sustained progress throughout the north american region especially is allowing for the natural economic processes for integration can happen, and this implies labor mobility that cannot be determined by mandate or by decree. this is what we have underscored with president obama during this meeting, to keep on invoking the protection for the mexican laborers, whatever their migration conditions are in the united states, and our highest amendments -- commendments to the way that president obama has tackled the migration issue.

aside from defending the rights of the mexican laborers in the u.s., one day, instead of the mexican people have to leave their country because they are hungry or because they have to risk their lives, we needed economic scheme where we have great investments coming from the u.s., hailing from canada, and opening here labor opportunities that the mexicans me. i think president barack obama has responded to the issue on honduras. whenever we have discussed or agreed needs to be done to build the international actions that have been taken in order to reestablish democracy in honduras, to strengthen oas and the delegation that is about tegucigalpa, the mediation actions for costa rica, carried

out to be established constitutional law in honduras. this is not about a person or a mother, not about the president himself, or per se, it is about the constitutional and democratic life that ought to be defended in regard to the international legal framework that we have all agreed upon, -- and one moree expression -- those who have arguments about the intervention of the united states in the region are those who now are claiming for the determination or the intervention of the u.s. in the region, no matter how legal this action might be. we have to resort to international law and international instances beyond the intervention of one single state or even more. the intervention of one single person to resolve such a

disputed issue. this is about to be taken. today, we congratulate ourselves that president obama is leading the administration of the united states, but in the past, that happened, but in the future, we don't know who might be president next. i am not of those who share the idea that the u.s. has selected as the ultimate judge, and the ultimate sovereign results for to the intermediation in affairs in our country. yes, we have to open the path to the oas, the regional groups we have formed, such as the groups so that our friends of north america, the countries that before and honduras, that of grand central america -- that the friend honduras, that the friend at central america, in

observance of international law and the rules we have, we have to form a group of friends of honduras that, with the help of the oas and the corresponding actions. >> just briefly, secretary napolitano and our officials have been meeting regularly on the management of the shared border. i think we have good, corporate relationship in that regard. it is obviously always work to be done. let me be clear, from the canadian perspective, we look at our border as a line between the two closest countries on earth. we have the largest trading relationship of any two countries on earth, but we also share security concerns. i've said repeatedly and i say

again that there is no such thing as a threat to the security of the united states which is not also a threat to the security of canada. that is why canada has been a steadfast ally of the united states with naphtha and -- nafta and norad for many years. we want to address the security issues that the united states addresses and in a weight that it does not impede commerce and the great social interaction which has made our two countries so close over the decades. i'm just also going to weigh in a little at, as a friend of the united states, on the question was posed to president obama. i were an american, i would be really fed up with this kind of hypocrisy. the united states is accused of meddling, except when it is accused of not meddling. and the same types who are demanding the united states

somehow intervene in honduras are the same type of people who would condemn longstanding security corporations in columbia and the united states, which is being done for legitimate security and drug traffic reasons that are in the interests of all the countries of this hemisphere. mexico and canada are involved in the mediation effort in supporting the mediation effort on president areas that the united states is very forcefully articulated its concerns and the desired outcomes in that regard and has been very supportive of those of us who are working in multilateral process to deal with this serious issue in the hemisphere. i think that is precisely what we want to see from the united states, the united states that lead on issues of values but is very supportive of all

collateral times to deal with challenges that we all face. >> thank you. >> muchas gracias. >> it ends here with president of the united states -- >> the president and his north american counterparts, wrapping up this summit in guadalajara, mexico. following the summit, the president will return to washington later this evening. if you missed any of the news conference, he conceded and in its entirety tonight at -- you can see it in its entirety tonight at 8:00 eastern on c- span. the white house is having a round table this session on health care this evening with nancy-ann deparle, and policy analysts, state and local officials, health industry experts. live coverage in 25 minutes on c-span.

>> this fall, entered the home to america's highest court, from the grand public places to those only accessible by the nine justices. the supreme court, coming the first sunday in october on c- span. >> how is c-span funded? >> donations. >> private contributions. >> honestly, i don't know. >> advertisement? >> how is c-span funded? 30 years ago, america's cable companies created c-span as a public-service, a private business initiative. no government mandates, no government money. >> and now your calls and comments from today's "washington journal."

not merely to represent -- misrepresent that insurance reform legislation but to disrupt public meetings and prevent members of congress and constituents from conducting a civil dialogue. these tactics -- tactics have included hanging in effigy one democratic member of congress and maryland and protesters holding a sign displaying a tombstone. saying, just say no. vitter op ed continues -- these disruptions are occurring because opponents are afraid not just of differing views but of the facts themselves. the drowning out opposing views is simply on a very -- un- american. drowning out the fact is how we failed on this task for decades. the first fact is, health insurance reform will be more patient choice. opinions of speaker pelosi and

for the majority leader steny hoyer writing in today's "usa today." do you think these disturbances are american? the words of the speaker and majority leader. if you agree, the number to call is -- additionally, in "usa today" i have an op-ed piece on the same topic. disinformation may have marred the health-care debate. there are valid reasons to oppose some of the ideas percolating in congress, chiefly the lack of credible financing mechanism but the distortions have become so numerous that they have often one of the politifact pants on fire award. the lancaster, pa.. you disagree. it is not an american. these shouting and other instances? caller: i have my tv turned

down -- i believe it is very un- american. go ahead, you are on the air. i do agree that people need to be able to voice their opinion without being screamed down and stuff like that. i have had very, very hard times with insurance companies and for what they do, it is very on american. people out there aren't given this great insurance unless they are management. people of us who are working and given these things and the costs keep going up and the co- payments going up, payments would have to pay afterwards go up. then you have insurance companies telling the doctors what treatments they can have or did during treatment. i have had three family members with cancer who were denied to

have anything done until it was too late and they ended up dying. this is not right. you can't make billions and not expect somebody to be losing out. host: california. good morning to -- excuse me, stuart, florida. joanne, you agree that these disruptions are american, correct? caller: absolutely. i personally feel they have been incited and encouraged an organized and pushed forward by fox and news. i think fox news is the worst thing that has ever happened to our country. it is totally on american and there is nothing that they ever supported that has been good for our country. host: "the washington times" has fury on health care. congress on recess, tales from home. they write john dingell,

democrat, and lead author of health legislation did his best to remain composed even as many constituents and other residents argued that the plan is socialized medicine and rained down. against a small group of supporters for the plan. a picture of congressman john dingell and some folks gathered at one of the town hall meetings. columbia heights, minn.. good morning. you agree it is american. caller: i agree it is un- american because they don't let the other side talk. my answer is, i think lincoln made a mistake. i think they should give up their medicare and their social security that they find to be socialist or communist. i think they are very hypocritical and preventing other people from wanting to go through and try to have a fair approach to health care. host: do you have experienced locally? caller: our local representative keith ellison represents me and

his town hall last week was shouted down. i will tell you, the people who voted for him, the people who shouted him down did not belong to our district. they did not even vote for him because they didn't live in the district. host: where did they come from? caller: it came from other areas, a lot go -- came from where michele bock commend represents. i did not go to hurt town hall. -- michelle bachmann. when you don't allow the discourse to take place, that is what is un-american. everybody is entitled to their opinion. host: editorial is in "usa today," and american attacks can derail health care debate. do you agree, they are on american? east point, ga., what are your thoughts? caller: i really wouldn't use

the word on american. i would use the word that they hate obama. these people lost at the ballot box. now they are trying to bully their way into power. i have never seen such a set. i did not know what word to use. dumb americans. they talk about the government being between them and their insurance companies, they are cheering and aiding and abetting the insurance companies. i have more problems with the insurance companies than i have ever had what the government. i don't mind them voicing their opinions but at least voice opinions in truth. host: who is your insurance company? caller: i am like a truck driver, and in the last three years my trucking company has changed -- it was blue cross or blue shield, then went to aetna

and we just went to another insurance company. in the last three years my insurance company has charged -- and extra 35%. host: about 10 more minutes on your calls about whether these disturbances or is a -- incidences' in some of the meetings across the country are as the speaker and majority leader writing in "usa today" are an american. "of the hill newspaper writes the deficit grew by $181 billion in july -- "the hill" newspaper. the deficit and a record of 13 trillion dollars in july. dole disagrees, not american. caller: i very much disagree. i have gone online research in this bill, and it is enormously complex but there are

apparently three major bills out there that everybody claims to have read. i would really like to meet those people and talk to them about it. but i don't believe that they have. if we are going to be spending a huge amount of money, there is going to be serious dislocations. there are accusations that seniors will lose. there is just an enormous amount of information that needs to be -- before we say yes or no. host: another call:maryland -- host: you agree that they are un-american. caller: if two sides cannot sit down and talk about the issue, it is un-american. everybody knows there is no bill yet, and has become blind and looked at in their totality and not three separate bills and you picked the worst of all of them and complain about them. sit down, talk to each other.

if one side is shouting the other side is not getting their point across. host: have you heard about any meetings near you that you might attend or might be interested in hearing? caller: well, no, i've worked a lot of i am not able to attend. i listen to c-span. well of -- i am well informed. host: thank you for your call. a column in "the new york times" on some of the political behind- the-scenes of the health-care debate. the rowdy start of the august congressional recess has galvanized activists on both ends of the ideological spectrum, it makes it tougher for negotiators to stake out a middle ground. especially in conservative locales that democratic centrists call home. in new jersey, jason. disagrees , un-american to stand up and disrupt the meeting on health care? caller: thank you for c-span.

i think we need to be careful about using the word un-american that is a term that is very disturbing. i like to quote the first amendment, congress shall make no law respecting the establishment of religion or prohibiting the free exercise thereof or a breach -- abridging the freedom of speech, the press, or the right of the people to peaceably assemble. there is the key. now, these people are giving their opinion. they are assembling and would have to remember, this is america, everyone, we have a right to free speech and respect that right of all opinions. host: marion wood, missouri. go-ahead -- excuse me, this is lloyd from arkansas, he disagrees, it disagrees,un- americans to use these tactics. it is not on american. >> i did not believe so because

you can call your congressman here in arkansas and ask him a specific question or something and you never get an answer, you never get to talk to him. you always talk to a secretary. and i have asked him several specific questions and i just never get a specific answer. host: who is your congressman? mike ross? caller: no, sir -- yes, sir. host: one of the blue dog democrats? i did not mean to interrupt. caller: i asked him about illegal immigration, i asked him about the part of the constitution that says a child born of an illegal immigrant here in the united states is already a citizen. i don't believe that -- never got a response from him. host: in your comments based on

an op ed this morning on "usa today." by speaker pelosi and majority leader steny hoyer, un-american attacks cannot derail health debate. missouri -- agrees it is american. caller: i do not agree it is un-american. i am against the government health care plan -- it did not work in england or canada or the two states it has been tried here. i believe people -- reason why people like getting a little heated at these events is because congress is trying to push it through before the august break so they felt the need to really go out and strongly oppose it. they are going to require an hour of counseling for the elderly, 80 or above, to say you can kill yourself. they are going to require counseling. not only are they going to try to get rid of the babies with

abortions, but they are also going to get rid of the older people who are costing medical money. host: have you read that segment of the bill? it has been talked about. what are you reading the information on that particular piece? caller: this bill -- it is in there -- i heard it on fox news that they are going to require an hour of counseling, and as far as reading it in the bill, i have not read it in the bill, but i am against it, and i really believe that people are being heeded because they're trying to push it through. host: folks can read it themselves, the regulation is linked on c-span.org. front-page health story on "the washington post" on the swine flu that will be an issue of discussion, the three leaders of mexico, u.s. and canada preparing for the swine flu return. new wave expected after virus flourished. shirley from st. louis.

hostcaller: i think it is very american for people to go and have their say. i think people are fed up of the way things have been rushing. we had no say on anything about the stimulus, we had no say about the terrible budget that was passed, no republican, we were not even represented. the democrats did all of it. and i think people are afraid the democrats will give us the health care bill, what ever it is. when you say american -- i did not hear any of this talk when thousands of mexicans carrying mexican flags democrat -- demonstrated a los angeles and all over this country when the immigration bill was being considered some time ago. i never hear any of this wind acorn hired buses, buses of unpaid volunteers to go and

carried signs -- you look at the signs of that these people. . no one went out to some printing company and had thousands of signs printed. host: do you think on both sides, do you think outbursts and other sorts of efforts at these meetings is being orchestrated by groups on the right and by groups on the left as well? caller: i know they are orchestrated by groups on the left. host: not conservative groups as well? caller: no, i think the people here things -- you look at the audiences, they are older. you look at them, and they listen to c-span, they listen to fox news, they listen to abc, nbc, and they feel helpless because just as the stimulus bill went through, just as the budget went through, there is no

say and no representatives on our side. host: a couple more minutes. jamie -- jamie from oakland, california. caller: i do believe it is un- american, just like the past eight years americans felt it was not patriotic to voice an opinion in a peaceful manager and a first amendment -- as the first amendment says. yes, it is un-american for them to take on the policies of russian lombok and fox news and to disrupt -- rush limbaugh and to disrupt the organized campaigns. you noticed that most of the disruption is in democratic town halls. they are not disrupting republican town halls. that let's you know it is

planned. unfortunately like this last lady said, they are usually older people who are already on socialize medicare and either don't realize they are on socialized medicine already. texting host: thank you, jamie. a common from teresa from twitter. peaceably assemble. " the new york times" on the front-page reports on how people start their day with waking up and getting on line first. coffee can wait, the day's first stop is on line. i will pull this and just read a piece of the story. the surge in early risers is reflected an on line and wireless traffic patterns. internet companies that used to watch traffic levels rise only when people booted up at work now see the uptick much earlier.

a boston company that analyzes internet use says web traffic and the united states gradually decline to midnight until 6:00 a.m. on the east coast and then a huge morning caffeine jolt. nextel last caller, new york city, good morning to lowell. >> i am a resident of new york. i think it is completely american. i am so glad to see americans like myself getting agitated, going and letting congress know what we feel is going on. i am retired. i developed whatever wealth i have in my life. i would like to be able to leave that to my children and errors and their children, and i am devastated to see that my grandchildren and their children will be paying for what is going on in washington now. everything that the democrats

claim we do are the tactics that they use. gestapo-type guardrds at voting booths. host: all right, we will end it right there. >> the white house is holding a roundtable discussion on health care today with the administration's opposite health reform director nancy-ann deparle, and policy analysts, health care industry experts. live coverage coming up shortly at 2:00 p.m. on c-span. in the meantime, more headlines and phone calls from "washington journal." back. we will start with the front page of "the wall street journal." "taliban is now winning." this is the report from peter spiegel in washington.

"the commander, general stanley mcchrystal, has offered a preview of the strategic assessment that he is going to deliver to washington later this month, saying that the troop shifts are designed to better protect the afghanistan civilians from rising levels of taliban violence and intimidation. the coming redeployments are the clearest manifestation on the death toll and spike in military deaths in afghanistan." we will look at that chart this morning, the mounting toll of the u.s. troop casualties in afghanistan. another article this morning from the philadelphia -- "philadelphia inquirer." de "the president's national security adviser did not rule

out adding more u.s. forces in afghanistan to help turn around a war that he said yesterday was now -- was not now in crisis. james jones said the united states would know by the end of next year whether the revamped war plan obama announced in march was taking hold, with new benchmarks that reflected a redrawn strategy. the outline is expected next month." on the weekend talk shows, jones did little to dispel the rolling expectation that obama soon will be asked to supplement the 21,000 additional troops already approved for afghanistan this year." we will speak more in the program with congressman sherman about afghanistan. your chance to weigh in his right now. jeff, good morning. caller: thank you for taking my call. i believe that the obama

administration is doing the right job by making the focus of afghanistan -- i want a president who believe we never should have been in iraq in the first place and that the real problem is the radical extremism in afghanistan and pakistan. host: how you think that the administration has done so far with the situation in pakistan as it relates to efforts in afghanistan? caller: it is hard to deal with the situation in pakistan given that you are dealing with a government that is supposedly supportive of the u.s.. they can only do so much without pakistani government approval. but i truly believe that some of

the extremism is in pakistan and they have to be dealt with as well. host: thank you for the call. j., north carolina. good morning. caller: thank you for taking my call. you had a guest yesterday on c- span, michael shuer, he some of the situation in afghanistan perfectly as far as i am concerned. that this will always be a tribal society. that the government is completely corrupted by the drug trade in that afghanistan is not worth of american life. it is not called the graveyard of empires for nothing. i think that the best thing that we can do is get out. i do not see us changing anything. i do not care if you put half a million troops there. i do not think anything would

i do not think anything would change. what do you think of what the president has already authorized? 21,000 more, this assessment is set for september. what if the assessment says that we need more troops? >> i'm sure that it will. all that you are sending over is 21,000 bull's-eyes. you are never going to defeat any kind of radical army like the taliban unless you send over 1 million troops and pursued them night and day, which we are not willing to do. host: thank you for the call. washington, d.c., independent line. welcome. caller: good morning. this war, the afghanistan war, it should never have happened. we know that september 11 the al

qaeda people started a waging war. we should have systematically eliminated the people that attack us. there was never a single afghan war before september 11. host: much was made, remember, in the 2008 campaign that we took our eye off of the ball of afghanistan and that now that we are refocusing on that you are saying it should not be our focus point. caller: it should be, but it should be against al qaeda. the afghani people are nomadic. i have come here to america to raise my children. when i see these young americans

being killed, it just bothers me. host: when did you come to the u.s.? caller: 24 years ago. host: thank you for the call. here is a picture of a marine from "the new york times." the headline is "drug chieftains tied to taliban. generals assert legality, a list of 50 to be caught or killed. 50 afghans believed to be drug traffickers with ties to the taliban have been placed on a pentagon target list to be captured or killed, reflecting a major shift in american counter narcotics strategy in afghanistan, according to a congressional study to be released this week. united states military commanders have told congress that they are convinced that the policy is legal under the military rules of engagement and

international law. they also said that the move is an essential part of the new plan to disrupt the flow of drug money that is helping finance the taliban insurgency." what is next? that is our question this morning. next caller, good morning. caller: good morning. thank you for c-span. i have been taking classes in middle eastern studies. both what is normally considered the middle east and the greater middle east, which afghanistan is a part of. host: where are you going to school? caller: i am out of school but i am a teacher and through our program we have different ones, one of them is middle eastern studies. i will make a flood, i am going to school at george mason, that is where the program is that. what it has shown is that afghanistan is a country that

should not be a country. it was created by pakistan by the british. pakistan used to be two different countries but they split apart because the ethnic majorities could not get along. afghanistan is made up of many to from parts -- many different parts of ethnic tribes. forming them into one country is impossible. i do not think that america can win because it is a guerrilla war in a mountainous region. i do not know what we are spending our money on. it feels like iraq again. we are fighting to win and get victory for something where we do not know what that will mean. host: are you a history or political science teacher? caller: i am actually english as a second language teacher. i teach a lot of children that

come to this country. there is a large afghani population here from afghanistan. host: how many languages to you speak? caller: four. english, spanish, chinese, and i am learning arabic. host: thank you for your call this morning. we are going to michigan, charles, independent line. caller: hello. afghanistan could easily turn into another iraq. the lessons we have learned their, we should carrythere, -- there, we should carry them over. too much is being used from the ridiculous bush cheney policy.

host: when you say leftovers, do you mean military leaders? caller: people in the pentagon, guess. as far as the drug problem, a number of countries in the world are using, as a replacement for morphine in the spectrum of pain medication, they are using heroin. host: here is a quitter. "the saddest part of the entire war is the fact that we never had any substantial evidence linking bin laden to 9/11 -- and for what"? michael, fort lauderdale. good morning. caller: my comment on afghanistan is a lot like what we have heard other callers say. it seems that this is an area of

the world that is completely undeveloped, nothing really there. hardly anyone has any education. it would take decades to make any real difference in that part of the world, if we ever really could. and i really think that our military did a phenomenal job in iraq. they never got the credit. it was a debilitating thing to fight urban combat. if you go back and look at instances of the second world war, where they had no rules at all, it was demoralizing for soldiers to fight in an urban combat zone. we did this brilliantly in the wrath, but it is not the case in afghanistan. different typography, with the chinese and the russians putting all kinds of sickness in there, like we were doing when the russians were in afghanistan.

host:@@caller: there will not bn instance where we can say that. i am not downgrading the military, they are an excellent fighting force, but there is no place that can hold it down. if you look at history, it is replete with military units that have entered afghanistan and have never been able to make a substantial difference. the gang is con was chopping people's heads off, no care what ever for the local population, and even they had a hard time controlling afghanistan. how will we do it? especially with all of these rules of engagement. if we keep a limited number there, keeping things under

control, that might be the only way where we could really make some kind of stability. we tried replacement crops in colombia and other places where they were growing drugs. we asked them to grow different crops, you just cannot drive that out. someone who has been growing you cannot just have a cultural shift like that in just the amount of time. host: this is an article in iran is today in the "washington post." the headline says, of an " analysts expect long-term costly campaign in afghanistan." he writes that since the campaign in afghanistan eight years ago, the u.s. has spent 20 -- to under $23 billion on more

related funding for that country. combat operations expenses have grown exponentially from $982 million in 2003 to $9.8 billion last year good morning on the democrats' line. caller: i would like to comment on the situation in afghanistan in the first place, we are worried about helping the united states. why don't we just stop the two wars and then we will have enough money to not worry about who is going to pay for this or for that. this war is politically motivated. there should not be any war and the new -- their work should not be no war anywhere. in the first place, we should not have any troops in any foreign countries or to kill people. we are going over there with the soldiers to kill. russia fought there a little

while. and just took off and left it like it was. and russia is in good shape. russia is not worried about sending troops anywhere. there is no reason to be in afghanistan or iraq. now, you've got a new president, he says he's going to take us out of here or there. this guy is just double talking. host: we started our conversation talking about some of the conversations yesterday. your is some of what was said yesterday on meet the press. >> it is obvious to turn their responsibility over to the afghans as quickly as possible we're doing that three ways. one is in march -- in march, we announced a comprehensive strategy that was not just focused on troop strength and

security, although there is a minimum that is required, but also, the cohesion of security economic element and good governance and rule of law from local mayors all the way to kabul. we have generated them over a period of time on the security pillar. 47 sovereign countries are on the ground in afghanistan. the u.n., nato, the european union, the world bank, all sorts of non-governmental organizations, all the instruments are there to turn this thing in the right direction. the question is, how you get them to work more exclusively? that is the new strategy. host: until 7:30 a.m. eastern, a what is the next step? that is our question to you here is a quitter. -- twitter. good morning to mayville in york

city. caller: good morning. i do not think this is a winnable war. i think we spend way too much money over there. we should get out as soon as possible, if that does not make any sense. you are just bombing people and killing people and people are getting killed. it does not make any sense. host: another call from new york on the democrats' line. you are on the air, go ahead. caller: i think the big problem that everybody should focus on is the fact that the american people are smart and want certain things, but our politicians and not care what we want. that is the thing. and the reason is because they all get so much money that they do not care what we want. they talk about health care and they are always talking about how the problems with canada,

the problems with massachusetts, but they do not look at the of the countries that have wonderful health care. and that is because there is too much money against the kind of health care that we really need. until we all get together and see this and with the republican-democrat argument echoes on and realize that we are one country and our politicians do not care what we want any more. >> will leave this record portion of today's "washington journal" to take you live to the eisenhower executive office building at a roundtable discussion on health care hosted by the white house. it just got under way. live coverage on c-span. >> the reform the we're talking about offers a major opportunity to improve the quality of our nation's care leading to improved patient health and experience, but also, lowering costs. i'm looking forward to what some of you have to say in doing that. we are joined by health care leaders that are developing advanced models of primary care

that address these challenges. we have representatives from state medicaid programs, health plans, integrated delivery systems, and physicians societies. we're also joined by academic experts. we appreciate your willingness to come and joint-share your perspectives and expertise on how we can advance these primary care models. we have people who have trouble the long way and we appreciate your taking the time to do that. i am also joined by several colleagues who are working on the administration meanwhilteam. -- star off by introducing ourselves. >> my name is kavita patel come out advisor for the office of public engagement and governmental affairs. >> and i should have said, i am nancy and apparel. -- nancy-ann deparle.

>> i'm barbara smith, special counsel in the office of health reform at hhs. >> i am dan palino, ibm's general manager >> i work with the national economic health care. but bob phillips, a family physician and part of the american academy of family physicians. >> i am the policy director for the medicare program. >> can store, a professor of health policy at any university -- ma university. >> i am chief of staff of the health care reform team from the white house counsel's office. >> i work on the national economic council on health care policy.

>> i am a family doctor and budget department of family communityç medicine at the university of california san princess go. >> i am a senior economist at the council of economic advisor working on health care policy. >> i am senior executive for strategic initiatives at the national committee for coalitions. >> and the director of health care transformation for the ibm corporation and president of the patients center primary-care collaborative, which is an umbrella organization representing about 400,000 physicians and most of the fortune 500 to relieve dry out a transformational change in the covenant in a way that we buy care and deliver care for primary care. >> i'm the ceo of the american college of physicians and an internet as -- internist. >> i will assess the health system's parts for the purposes of this meeting >> i am a family

practitioner with a background [unintelligible] >> i am the director for the vermont for health and a pediatrician as well. " a family physician who practiced for 17 years at group health before taking on new rules now i'm president of the medical group and the owned and operated delivery system. >> i am the principal investigator for the cms practice group project. >> i am a family physician and a national medical director for performance measurement and improvements >> imb deputy director of the colorado department of health care policy

and financing agency administers the public health insurance programs like medicaid and our schip program. >> i am david dorr, a practicing doctor at oregon health and science. >> i am a family physician with carolina's health care system now. i am the chair of the community care in north carolina and formally the medicaid director and state secretary of health. >> i am with the national economic council curator of one to thank everyone for coming. -- i am with the national economic council. i want to thank everyone for coming. i want to take a few minutes to talk to you about another person to event primary care and frame a discussion for afterwards.

as nancy-ann said, we are thrilled that this year we got health care reform in ways that could reduce the costs for american families and businesses, increase the quality of care and expand access to millions of people today's discussion is going to be about improving the quality of care. the around the table we have folks to -- who have done amazing things to improve the way patients receive care and will only accelerate the improvement of one to talk a bit about the changes in quality that we foresee coming, which many of you and body in the delivery system. at the first is, we're one to incentivize quality, and the thing that we are what you hear today is all about rewarding quality of care and think about ways that we can organize in ways like you have. -- preventive care is not done

because of cost. we will make sure that is accessible to everyone because that actually reduces costs and improves quality for everyone. coordination is 27 that all of you have thought a lot about. and we will think more about it. patients with multiple diseases actually get the right care for their combination of diseases and for each disease, and for the care team, no clues to charge on what needs to happen there is a lot that goes into that and it has to be improved making sure that patients get the right recommended evidence based treatments. too often we fall short in evidence based care. your practices of some of what ways to ensure that evidence based care is offered to people and when it is not, that a remedy is found to get them on the back -- back on the right treatment you all caught for

ways to organize the care system to avoid duplication and avoid things -- and to do things that are not done. there's a lot of frustration for families and patients. it is costly. again, we are going to talk about ways to ensure that communities and families and patients are much more likely to be informed and cooperative in the care. finally, we will expand access to the millions of peopleç that do not have access today. primary care is something that too often is not in place for patients. but what we refer to when we say primary care is a doctor and a primary care team who is responsible for making sure the patient working with them gets the proper care, that the patient knows who to call, if

your questions you have someone that can answer. if you have concerns about what to do, then there is a practice that serves you. most of us in this room does the -- do deliver that kind of care to the patients, but it is too often not the case. next, i want to point out that a round the table is incredible impact. we have seven systems that have all taken primary care. we will hear stories today about -- and a north carolina said they have saved $1 million already taken care of medicaid patients. we have a set of patients that are different and complicated in different ways than the rest of the population that alan is going to talk about.

there is a pediatric carry with remarkable improvement in the science based metrics. group health has very quickly avoided a lot of the emergency room visits that would have led to frustration expense and fear for families. we have, i think, some compelling story today and what is amazing about these stories is we have talked with these groups a little bit more about them and they are things said our committee wide. they are not limited examples. in today's discussion, we will talk about how we can get more patients with more benefits that we are talking about today. as we go through this, there will be four elements. there are four things common to all of these practices. first is this notion of care coordination. it is not left to chance, what happens after a patient sees a

doctor or nurse. there is a follow-up process to ensure that whatever is supposed to happen, happens. it involves not just information technology, but teams. there is no one person that is in charge, but jobs that need to be done by a full team. patients know what to do, there is follow-up incentives in some cases of the patients are rewarded for doing the right thing, but there is much more education that goes into the care of these patients and practices around the country. easier access, in these practices, when you call them the answer -- when you call them, they answer on the first phone call. that is not typical. in some cases, the practices are open nights and weekends. there is an alternative to emergency rooms and it is much simpler to communicate.

and finally, david driven. each of these practices utilize how the -- all the information technology to ensure that the immigrant -- interventions can be taken before there are complications. we're going to hear a lot about how information technology makes care better. i am thrilled that we're what you have these stories and that there are similarities, but also that they are meeting the needs individually of their patients. allen is going to go first. each person gets about five minutes. and i'm going to hold of a sign that says one-minute warning. and i have to cut you off if you go over, which makes me very anxious. himal been that we can stick to that. we do not want to go -- i am hoping that we can stick to

that. we do not want to go into too much detail. we will hold the questions for the end. >> i appreciate the epperson dtv year and talked about note -- the community in -- i appreciate the opportunity to be here and talk about the opportunities in the carolinas. we have to overhaul the current fragmented system. first, there must invest in a primary care. the values and principles outlined in the joint principles for primary care is a pretty good first and fundamental step for reform. community care is an example of the value of just such an investment. we started about 10 years ago with this project. community care is the combination of the 14 major

local health care providers and it is built around primary health care. it also includes all the other physicians,ç local health care providers, and particularly our hospitals and health department of social services and others safety net organizations. this partnership delivers the patient-centered primary care to medicaid and schip recipients to low-income adults and children in our state. the net board's have run over 4500 primary care physicians and 1360 locations all across north carolina, all 100 counties, and manages little -- a little over 1 million patients. this is what the map looks like of how the providers have self organized. kinder-care improves cost savings to our state using three critical elements.

the first, primary care physicians service and medical home, or a personal position as -- for the patient. second, local not-for-profit networks are in virtual integrated health system that linked the primary care physicians and patients, again, concentrating on the doctor- patient relationship. it is like the glue in the communities. these networks provide the needed position leadership and local collaboration in order to create a local solution to improve care management and quality. this provides a flexible structure that does prove to be adaptable and the rural areas as well as the largest academic health thisystems. with a blended monthly fee that provides funding to the network to provide the local resources to the patients and the primary care doctors, such as case managers, care corridors,

pharmacists, medical directors, and the local infrastructure to make sure we improve care. this ensures that the optimal support is provided to patients and received -- and results are achieved locally. community care has demonstrated why improvement, cost savings and is phenomenal growth since it is now statewide. it has documented significant savings, exceeding $100 million a year since 2003. in short, north carolina has been successful in managing the costs of its health care program mainly through a clinical management strategy rather than a price and remove the jori control mechanism. committed to care is now the centerpiece health care strategy in north carolina and is accepted by patients and providers. is a value-added proposition in this community. the legislature has mandated its expansion to schip and the

committee care is now working on a demo that will allow us to care for the sixth medicare and fully eligible -- for the sickest medicare and fully eligible. the local infrastructure work both in urban and rural areas. as well as public and private systems. the path for reform efforts can be informed by a lot of folks around this table in a really high functioning of systems. the problem is the most of our health care delivery system is not in a delivery system at all. some of the lessons learned from north carolina show the value of how you are investing in patient-centered primary care.

some of my suggestions for improving would be making sure that we adequately reimbursed pcp's, making sure we have enough primary care doctors to meet the need some of our folks. also, we revel two lines of policy and payment decisions to get certain acts as an comprehensiveness. we need to fund the additional care coordination strategies both at the practice and community level and provide the flexibility for four primary care physicians to link together outside of our risk model. everything that we did was that you have to reinvest the savings to get growth in strengthening local systems and get meaningful and lasting growth. there is a need for primary care physicians to undergo this

transformation through an extension model or some local model in a community. i appreciate your to to to be here to participate in the discussion. and >> david? >> as i said, i am an internist and i practice informatics as well and one thing we do is study the way technology can improve care. in talking about a care manager applause pilot and then healthcare and in the context of gloria. she is 75 and i wish you pictures of her withç her remission in a little bit. she is active and says her health is in fairly good. she is doing pretty well, much as five chronic conditions. diabetes, a bit of depression, some cardiovascular disease, and she's having memory difficulties.

we know just from that she will probably see an average 13 providers a year. she will fill 50 prescriptions and is 90 times the risk of hospitalization verses know what -- versus someone with no chronic conditions. medicare patients like her account for about 42% of the cost. so, where this was developed, these were the patients we wanted to target in primary care to keep him healthy and get home. the model is simple. it is a care manager and a primary care team that has this of the tell them permission technology to help them. we use that to help do care coordination and other tasks. we have seen some successes around hospitalization. we have improved quality around quality and efficiency. we started doing this in 2001. in seven clinics vs six

controls we basically have built this system with the care managers. they saw about 70,000 patients in those clinics. the care manager saw about 4700. we compared this -- would compare these six clinics on quality and utilization. we have since in the last few years done dissemination of in 75 teams at ohsu. the model is simple. gloria would be referred by her primary care provider to the care manager. usually, the care manager comes to the room and joined the visit and they work out together what gloria and her family needs to stay healthy. camera editors receive specific training to do a plan and then they have the technology to back of the plan and make sure it

works reliable. intermountain is a large, integrated delivery network, but they have multiple pairs and most of the paid did not come from a special pay for performance, just a small proportion. the leaders did this is because the primary care providers and system thought it was a good idea for satisfaction overall. the care manager saw about 350 active patients on average in the pilot. the help i tearoom help them to do care coordination and tracking, to never lose track of the patient who is at risk and it had a centralized reminder system that had protocols, but also the ongoing task around social needs that these patients so often face. scheduling improve in access as well as a access to the committee and the evaluations were regularly program. the health plans initially were

done by the medical group, but since then we have had different payment models that i will discuss at the end. we are working with federally qualified health centers we are working on. what are the results? we improved admissions about 20% to 40% and we improved guidelines about the same. patients in the clinics were living longer because we improve mortality. the people that were living at high risk to an exacerbation of their illness that could lead to death. all of this led to significant savings, which led intermountain to double the size of the group. per patient, we saw about $640 to succeed hundred $50 per patient. in conclusion, people are much happier. the patients and their families called it a lifesaver. they felt like they could not

live without it. and physicians felt they could work smarter and the pressure on their primary care was -- the anstrom treadmill that many primary care physicians feel like they're on was lessened. the computer tools were an absolute godsend. we really felt like it was successful at what we have done since then is told this out at more than 75 clinics across the country. a lot of what i'm going to save for the summary is going to be focused on what those clinics told us. next slide. a first, we found that the care manager role was essential. most clinics had a nurse, but not a care manager. we found nurses and social workers were great. although, some small groups needed a combination that did

the care management together. training was essential. it was a new role for many of our care managers and care coordinators'. hults information technology was essential. everyone of our initial practices and most of the dissemination had an electronic health care system. we help them to enhance what they had, but also to improve functions are on the care planning. we found our technical assistance was helpful to them and critical to their success. we found that most of them came back to was very excited about it, but since they were paying for most of this themselves, but they needed changes in the pavement that they got. that we call this paid for proactive care. for care coordination, goal setting, behavioral change and education.

many also find that per member month is helpful, although, selecting populations is helpful to see some cost savings. the clinics really needed to be able to refer -- they saw the need for every inch of the program to make the efficiency work. that is really all i have to say. thank you for having me. >> it is my pleasure to talk about the medicaid -- medical homes for children pilot that we initiated a couple of years ago and i would like to share some brief background to put it into context. in 2007, health care was a top priority of this administration and there was a deliberation to focus on children's coverage and health access issues. while we have a couple of excellent managed care plans

that participate in the manic- medicare program, the vast majority of our medicaid clients children are seen for service model. -- seen in the four service model. that raises some questions about the sustainability and increased costs associated with. it also raised the stand with which children or perceived -- receiving their vaccinations and receiving care coronation. at that time, only 20% of our private pediatricians and family practice physicians participated in the medicaid program and of course, at the top of the list for our participating is the lack of reimbursement, but when you really dig down a little

deeper, there are a variety of barriers to taking medicaid and schip kids. for example, there is a very high incident of missed appointments. we know why there are missed appointments because of this population sometimes have challenges accessing transportation to get to medical appointments. we know that there are social supports that are needed to support these families, a lot of other things other than just accessing health care. there are housing as use -- issues and economic, job-related issues. we have all of these concerns, and also in 2007, legislation was passed, medical help for children's legislation that

mandated systems and standards for medical loans for children to maximize the number of children that had medical homes. that was all supposed to be done in 12 months. in government, that is a very short time frame to implement something. we had to work quickly and we had to work smart. our approach was relieved to leverage the existing programs resources that were already in place for the pilot program. fortunately for us, we were well positioned to do this. our sister agency, the department of public health and environment -- they are a title 5 program and have been involved in that learning about medical homes and about plans. out of that work and my two passionate pediatricians created

a nonprofit association called the colorado children's health access plan. which was redesigned to recruit more private, primary-care physicians to except medicaid and chip, and then to provide support services for those practices. we also have a very robust outreach program. we have outreach workers throughout the state helping families at evaluating and using health care. the release serve in the health- care educator role. -- they really serve in the health care-educator role. we took all of the best aspects of what we were doing in the public sector and joined them with wet -- the good work that was being done in the private sector and greeted our medical

home pilot. our pilot design, we had 28 seats at practices -- 28 practices that included about 11,000 children. the organization, a nonprofit, provided services to families. the department reimbursed 8 feet to the organization's services. -- reimbursed a fee to the organization services. our incentive payments were increased $40 per preventive care visit. it does not sound like a lot of money, but it was enough money to get us going and in the right

direction. you can see our eps-dt outrage. their release serving as that care coordinator role. and -- out of reach. they are really serving as that care coordinator role. they're looking at the lighife cycle of the client, everything they need to access health care services. they work in the community to identify resources and link those families to those community resources. because this pilot is focused on children colorado has a very unique sort of philosophy. we are very family centered. i know a lot of talk about being patient centered, but when you are working with children, you have to look at the whole family. we are a family centered medical

home model. and yet our positions serve in the primary role of providing care in helping do the care coordination. the organization continues to provide the support services to my interpretation circuit -- services, again, looking at the whole child. what are the results of our pilots? as mentioned the -74% of our medicaid children in this pilot had a welch -- as mentioned, nearly 74% of our medicaid children this pilot had a wild child visit. we saw improved -- a well child visit. we saw improved health care outcomes. in 2006, colorado was ranked 49 in the rate of tiles would -- in

the rate of childhood vaccination kids. we are ranked 26th in just a very short timeframe. we believe our work in this area has been a big and dropping factor. preventive care visits increased, as previously mentioned. hospitalization rates have also decreased. it says on the slide that we are collecting baseline data, but miraculously over the weekend i was able to obtain some data on the physician and clyde experience. [laughter] the organization surveys the providers participating 90% satisfaction rate. i think it is significant. my favorite story about a private practice is that dr. crow went to a high-end

pediatric practice, never to medicaid or schip kids, led one of the physicians to the window and said, look out the window. did you know that 33% of the children that live in this neighborhood are all double -- eligible for medicaid and schip and you do not see a single one of those kids? that dialogue, that communication was a turning point. i dunno if it was killed. sometimes guilty works very well. -- i do not know if it was guilt. sometimes guilt works very well [laughter] again, i think the positions say they're willing to see our kids. they just need some help with some of the barriers. the family experience -- one parent quoted the mayor -- medical home is building relationships.

96% of our families feel the job provider create a medical home for their child and 100% feel the provider meet the families needs and cultural differences. why don't we move to cigna and you can chime in in the conversation? çthe satisfaction results camen at the last minute. irradicable of good thoughts for how to scale it. the one to make sure that everyone gets a time for the discussion. barbara and richard, if you could talk about what you are launching. >> sure, i will talstart with a note health care. we're pleased to share with you the partnership -- with the cigna healthcare. we're pleased to share with you the partnership we have developed.

we have accelerated the improvement of both quality and affordability of the individuals that we serve in common. have baseline, we have done very well in world and economic and urban settings. -- rural and academic and urban settings. hauwe have predictive models and other information to guide the improvement in care of the services. we had two problems. first, these clinical efforts were not ideally connected. we had to systems running parallel and we were not getting the synergy that we wanted to

get out of connecting those two systems. the second was at our primary interaction to exaggerate the point was that -- was a negotiated reaction over the past couple of years and it was not a reaction where we sat down and said, how we -- how do we improve both the plan and affordability? we developed a new program to get a that has the key concept and outlined their. -- concepts outlined there. one was, we said that the program had to operate in the open fee-for-service and armand kerridg-- environment. it provides incentives for them to work with their primary care physicians because it enhanced care coordination.

it improved the coronation delivered by primary-care physicians, not by forcing people to work with them, but by providing excellent service and that is what people wanted to do. the second is, the rewards for the program had to be based on an improvement of both quality and affordability. but it was not just about quality and it was not about just bolt -- affordability. both had to improve. we needed to administer those rewards three different payment mechanism instead of just increasing the fee-for-service mechanism, paid rewards out over a care management program. the third was that we wanted to obtain synergy. measure the direct face-to-face clinical programs with cigna,''s advance information services to identify patients that are at risk and improvement in care

opportunities. with those fundamental concepts we began designing our program in january of 2008. we implemented it about a year ago and we will have our first level of results later on in this fall in november. at this point, what i would like to do is to turn it over to barbara to talk about different aspects of the program and how they affect individual patients. >> as i mentioned earlier we were dissipated in the demonstration project and we were able to show increased quality compared to benchmark and national targets as well as savings throughout our three years of participation in the program. we're absolutely delighted and looking for a partner to see if the same things that we had designed as listed up there and your practice resources would be applicable to a commercial population.

it really is a different patient population. i will tell you a brief story about one of our patients that i hope this illustrates that we were on the right track here. mary is your next labor, my next-door neighbor, it could be any one of our sisters. -- mary is your next-door neighbor, my next-door neighbor, i could be when one of our sisters. her husband is at employed and fully insured. they have a couple of kids and a couple of grandkids. mary loves to cook and she really likes to scrapbook. her hunter is a fisherman and a hunter -- her husband is a hunter and a fisherman. she is a cancer survivor. she was referred to one of our care managers by one of her primary care doctors, who she sees most often because he just thought she was depressed and she was not getting better. no matter what he did, he really could notç make her mood improved.

our care manager was asked to do what care managers do, to make a recommendation to a local provider. hawewe actually call our patiens before they call us, which i think is really good sometimes. we do a screening tool for all our patients in primary care. at the personal health questionnaire, which is a score for depression. her score was 22, which is very severely depressed, and in fact, perhaps suicidal. our care coordinator was at least able to connect with mary and began speaking with her on the phone every week. they said small goals. sometimes they met the goals and sometimes they did not. she learned that mary grew up in an orphanage and throughout most of our life she was scared, shy, invisible.

she felt -- was frightened to get involved with people. and she was the barrier to going to aima dolle visit, not her husband, as she had previously reported. in fact, she started telling us that resto was so worried about her he began to take time off work to stay around the house with her so she would not do anything to harm herself. so, we are also losing the employe time from the employer's perspective here. she said one thing that kept her going was her grandkids. in one of the caribbean -- one of the things that care managers do is medicated reconciliation. she would take the list of medications that she thought mary was on and the ones that married -- was on and tried to get them to agree. it was not working. we have this medication list and they were not getting the words

right. called again, and lo and behold, mary admitted that she really could not read very well. so, she really did not know what our spiffy, patient family medical reconciliation list said. our care manager scheduled a visit, brought her in, her husband came in as well, and this woman sat down and color- coded and drew pictures on every single bottle of medication and on the medication as. fisher put a frown face for the anti- depression medication. she put a card for medication for hypertension, and she did something with food for her cholesterol medication at the same time, cigna shared with us that mary had not, in fact, filled her antidepressant medication in over a year. it is hard to get better from an antidepressant if you do not

take it. we in robert kennedy, her church, the visiting nurses association. -- we involved her community, her church, the visiting nurse association. mary is taking her medication and the last time we looked, her depression score is down to nine. so, she is under control. that is the core of what we are trying to do. we are trying to work with people living real lives, and doing real things, fully employed, getting information from cigna that we do not have, getting information from our care manager. we have a doctor who knew something was alright. we have a care manager who would not give up and we had some information from mcnatt to help us put this all together and that is what we're trying to do in this collaboration i'm going to give my side and close on that. we do this in urban communities, small committees, large communities. we think this is what advanced

primary-care practice is all about. the doctors love it. it takes off the burden of the paperwork. they get a patient that is ready to talk to them. the nurses love it. they're being able to practice nursing the way they want to practice it and what they went to nursing school for. and patients are like, oh, my gosh, you called me. i did not have to call you. that is what we're looking for. . .

>> they're measured against their peers. the improvement in afford ability essentially funds the bonus pool. how much of the bonus pool dartmouth gets, it's improved portability and improved quality. and that payment is made through a periodic care management payment on to the g code system rather than as a modification for the fee-for-service. so we feel that by getting the reward system lined up, by getting synergy and the clinical working together between dartmouth and that we're able to drive a much better outcome. >> thank you, we're hearing some wonderful patient stories and thanks for sharing mary. michael, if you would tell us what you're doing. >> yes, i'm president at group health physicians. like all of you, we seek better care at lower cost and we found

out one year at 29% reduction in emergency room and urgent care visits and our pilot paid for itself. our practice has 900 physicians, 250 primary care practices and care for about 400,000 patients in the state of washington. we have made a strategic long-term commitment to effective primary care to apply to all of our clinics. first we ran a two-year pilot and we learned from that pilot many things to learn to identify elements that we applied everywhere and we're 2/3 of the way through. indevelopments lead to belt quality, better patient and staff satisfaction and stabilize the medical cost trend. so what this really is about is putting the patient-physician relationship at the core of all we do. and then supporting that

relationship with high quality information, strong teams, and great access. this allows the teams to address each patient's acute chronic and prevention needs. that's in a nutshell. so what did we do? first we invest in our primary care teams. we add 30% of staffing, physicians, nurses, mid levels, pharmacists. then we decreased the number of patients that each physician is responsible for from 2,300 to 1,800. increase the visit time on a template from 20 minutes to 30 minutes. then we hit on real gold. we finally figured out how to really leverage our electronic medical record or e.m.r. i have a key point about this that it's not really about the convenience that these records allow for both patients and clinicians although that convenience is huge and can't be overstated. the real power in these systems comes because they allow us to

know our patients so that we can proactively address their care needs. that's what makes them really work. and we can address these care needs through a variety of prosecutes, from focused outreach to complex patients to simply knowing every patient's prevention needs at every visit and delivering on them. this of course increases our quality scores which is nice, but more importantly, it allows us to know what to do for each patient at every vitcht. we can also address populations of patients. example, 2007, we put in a new process to care for our 7,000 patients on blood thinners. we shortly decreased clots and bleeds 26%, saving over $3 million while giving better care. last point about e.m.r.s. clinicians throughout our system are adding to the evolving story about each patient. this kind of collaboration deepens our understanding and

makes it pretty easy, actually, to give up to date seamless evidence-based care. about access, we change the paradigm. we said patients, you're in charge. you tell us what access works for you, group visit, traditional face-to-face visit, e-mail secure message, phone visit, what works? you're in charge. we found that we could often resolve their concerns with a phone message or secure message saving them time, cost, and convenience. patients also can access their records, e-mail their doctor, order medications and make appointments online. this engages them in their health, strengthens the bond between them and their doctor, and ultimately puts them right where they belong at the center of their care experience. the results of one year if i can have the next slide are gratifying, at two years are even better. i need to point out the error.

the first line under cost productivity says we added 29%. that's wrong. we added $9 million or $10 million across our system for all of it, which is about 8% in primary care. so at one year, as i said, we saw 29%. that's where the number came from, reduction in e.r. visits and urgent care visits. we also found an 11% reduction in am latry care. the reduction in utilization actually paid for the pilot by one year. we didn't expect that. i had a briefing last week about the two-year results and it's even more compelling and i can tell you this much. it saves money, lots of money. also improves health outcomes like cholesterol management and people with coronary artery disease or diabetes and it enhance work satisfaction, decreased burnout. we have 12 applicants for every

post. based on these findings rear rolling it out to all 26 medical centers. we're about 2/3 of the way there. we identified the key ingredients for our system. we think these elements can be translated to different practices with different payment mechanisms and lesser levels of integration and we believe some of these key elements need to be supported by reform. example. we need innovative payment mechanisms that allow quality, integrated electronic medical records, more development of medical homes, collaboration between providers. that allows teams to care for the whole patient across the continuum of care, and that's how you get the benefits. most important, of course, is the experience of the patient. so i want to close with the words of a delightful 80-year-old woman. not only today, but continually, no matter when we come, we are treated promptly, court to usly, cheerfully and efficiently. in recent visits we are aware

of an extended time with the doctor, no longer a sense of rush. to everyone from the front door to the end of our visit, thank you. keep up the great work. thank you. >> thank you. great story. craig, talk to us about vermont. >> sure. first off, i want to thank nancy-ann and bob for having me here on the state of vermont. one of the things that drew me to vermont two years ago was the environment there and the commitment, the willingness of the leadership in the state, the government and the legislature to respect take on health care reform and do it in as comprehensive a way as you can imagine. and it's really visionary leadership and i think that's where this starts when you have in our case a bipartisan willingness to come together and to work on complete health care reform. that's what has led us to where we are as a state right now with our health care reform

models. i would just summarize it by saying what the state really wants to do is build this coordinated well-integrated high quality system of health. and where are we starting from? we're starting from a typical tapestry like the rest of america with independent practices, some big, some small, some affiliated with hospitals, poor areas, more dense and urban areas. we're starting with the same at that pointtry. how do you turn it into a coordinated system of health? if we start off with the first slide, it's summary of the timeline and we're in the midst of our first pilot and really working on testing this off across this mosaic of this health care environment that we have. we're working on three different communities. we hope to have 60,000 total patients enrolled in the pilots testing in new approach to health care. you can see the timeline on the bottom of the slide. we started planning this in

2007. that meant negotiating the financial reform, designing a payment model that could support high quality care. designing the technology that will be so critical for this. it meant putting in place the community health teams. we spent about a year getting the design, the strategies up. and then in july of last year, we started with the first pilot community october 2 and we're now getting ready to gear up the third pilot community. just as a brief summary of this, the uptake has been tremendous. as we have heard from the other participants, with the docs, the patients and with the families and with the surprising the hospital c.e.o.'s, the uptake of this and the engaging of this and the acceptance of this has been fairly rapid and so much so that this year, starting this summer working on statewide readiness for expansion of the model, much faster than we would have anticipated. if we go to the next slide, i can give you a key breakdown of

what the components of the health care model is. it really does focus on building primary care into being able to operate with just high quality delivery and so it starts with the payment reform and the payment reform that we have negotiated is with all of our insurers involved. i want to stress that. it's really critical to have all of the insurers involved in this so our major commercial insurers and medicaid, they're all paying the same way. what happens is the practices get scored based on national stands. this drives based on the quality of care how thorough the care, the great access, the practices get an enhanced payment. now it's on top of their normal fee-for-service. what are we doing here? we're beginning to balance out the pressures, the incentives for volume against incentives for quality, beginning to balance out that scale where it was all volume before. but that part of the payment isn't all it's limited to. we also -- it also includes our

insurers for sharing the cost for what we call community health teams and these teams are a critical component. the teams are made up of a hole mix of professionals. they including nurse coordinators, social workers, dieticians, the people that you need to make high quality health care work. the idea of having all our insurers involved and the idea of having a hedge team, not limited to a practice is how do you scale this? how do you work in a world where you have a small independent single practitioner versus large group practices, where you have some practices that are spread out in rural areas, others that are in more dense urban areas, how do you build a model that can work across this whole setting? that's the idea of the community health teams and of having the insurers share the cost, that these teams can be expanded, scale, include the number of people, the right mix of people that they need to serve a collection of primary care practices, not just one. and then the primary care practices are paid for delivering thorough care.

and what we have seen emerge out of this is an incredible approach to well coordinated care. we start with a team of five people on the community health team, but that's the new people that are put in place. what happens is they do such an effective job of linking to social services and other services in the community, the functional team is much bigger than the five. and we're seeing it translate into tremendous case examples. i was listening just thinking of one, i asked one of our docs for case examples today and one classic example, very similar to what you described is the 62-year-old woman living in a poor area in vermont, lower socioeconomic area, came into see her primary care doctor maybe once every two years. she has diabetes. came in last spring, turned out she had an elevated depression score, never really engaged in her treatment plan or getting control of her disease, turned out that she was more worried about the rest of the people in

her house being able to get their health care. the doc was able to attach her to the community health team, the nurse coordinator, the helen hedge counselor. they worked with her and connected her with social service that got her transportation to the practice. in jurblings a few months later, she has really solid control of her diabetes. she has had tremendous improvement in the mental health issues and this is a classic example of a patient that was going to be ripe for the worst possible health outcomes, a chronic decease with depression. she was going to be sick. she was going to have terrible outcomes. she was going to cost the health system a large amount of money in terms of hospitalizations and within a few months, this team working with the primary care doctor was able to turn that around. and those type of experiences have really led to rapid uptake in adoption of the model in the state and the desire to expand this statewide. the health i.t. is part of

this, the information technologies, a core part of it. it should live quietly behind the scenes helping to provide great care. it shouldn't be the focus of it. it should be the architecture that supports it. so we have electronic medical records where they have them connected through the regular industries with the health information exchanged to information can pass back and forth. the core information is where it needs to be for the community health team members and the practices and the people working within the practices. i just on the model want to emphasize a few things. not only do we have the health care deliver people on the teams, but we have including public health specialists so the department of health has prevention specialists for help on the team. and we're beginning to put together is public health and health care delivery working closely together to really go after improving the health in communities. through the health care delivery part of it just we just talked about, but also through the public health

aspects, improved messaging, the getting the message out there how to improve your health and how to build an environment that can really support a health think population. last -- healthy population. lastly on this slide, our model, our hospital c.e.o.'s have unanimously worked together as i mentioned for statewide readiness we are building it out for primary care practices. our goal is to have it in every hospital service care area across the state. we move on to the next slide thinking about evaluation, we have a corset of measures to look at this in many ways. the way we have heard about with all of the other programs, looking at the quality of health care, you improve the quality and you have this new environment with payment reform, with community health teams, with information technology. if you have this new environment, does it really change the way quality of care

is delivered? if it does, do patient get more screening tests and assessments that they need? if they get more assessments and more thorough care and they stay engaged and come back for visits on a regular basis and get about good follow-up, all of the rest has changed the health of this population. do they shift from the episodic care and acute care to more preventive care. if that happens, what happens financially? what is the impact financially on health care costs in the state? to that extent we have put in place a robust set of databases and we're going to look very carefully at all of these different layers of evaluation. the last thing that i just want to mention on the last slide, what do we really need for this to work and what we need is to even have more participation all of the insurers. we need medicaid participation as one of our insurers workingly closely to expand

this statewide. thank you for the opportunity. >> thanks. >> thank you very much more the opportunity to be here. the integrated system that includes a large group practice, a teaching hospital and insurance company. go to the next slide. we're not mutually exclusive about providers and participate in other insurers network and t.h.p. uses other community providers. in 2006, we concluded that we needed to develop a new care model to provide higher value outcomes for our medicare patients and members. our objectives would improve the quality, experience, and inefficiency in care for that population. we also believe that health care financing with a zero sum gain, higher costs today would lead to reduced coverage for patients, so we had to do this without increasing the total cost of care. the model was a result of this effort. we introduced it to one pilot practice in late 2006 and it

rapidly expanded it so this fall it will be active in 35 practices including now our nonowned practices covering 70,000 patients. the model was built as a partnership between our primary care physicians and our insurance company, t.h.p. the strategy was to provide 24-7, 360 high-dee in guidance for our patients. mrs. jones, at the center of our redesign effort, we developed new care processes and systems that could deliver high value care whenever and wherever she needed it. as a result our care team which includes the g.h.p. case manager follows and guides mrs. jones when she is at home, in the office, and specialists office, the nursing home or hospital. next slide, please. a patient had a primary care

model described by others today was the foundation for this effort. we expanded access and enhanced the capability of the office team. nurses provide many routine services often prompted by time of service reminders from our regular industries and care guidelines. when mrs. jones is seen for a diabetes check-up, the nurse is reminded to order the appropriate lab work and to schedule her annual eye exam. when she is ahome, her scale sends her weight to the nurses so they can monitor her status. office case manages employed at a ratio of 1 to every 800 medicare members. they identify high risk patients like mrs. jones, case manager that meets with mrs. jones and her family to develop an individualized care plan. she finds her condition worsening, she can call the case manager in the p.c.p. office using a dedicated phone

line. if she is hospitalized the case manager monitors her status in the hospital, calls her within 48 hours of discharge and arranges for her to be seen within seven days. the practice then developed value care systems to improve the services provided outside the primary care practice. the goal is to identify specialist and ancillary providers who are aligned with this value mission. the practices design their systems for hospitals and nursing home services to optimize care in those settings as well. under our quality outcomes program, there is a set of 10 quality initiatives targeted on improving quality metrics. they meet monthly to review their progress on meeting these goals as well as goals related to the domain of the member experience and cost of care. during these meetings they also discuss individual cases trying to identify opportunities to improve their care.

finally, the value reimbursement program in place added new stipends, both physicians and practice as well as a shared savings incentive model to our preexisting service and pay for performance programs. all incentive payments are paid on the quality targets. while these additional payments added cost, we believe that the improvements in the total cost of care would cover them. next slide. we did find that our effective care coordination focuses on the most fragile patients demonstrated positive returns quickly. our transitions of care program reduced readmissions to the population within three months. case management reduced total admissions within six months. next slide, please. it the results have been very positive and these are measured across the entire population. it's not a segment of high risk

patients. we believe these results can be projected over our entire medicare population. on health status, we saw significant improvement in metrics for measuring compliance and intermediate outcomes for diabetes, coronary artery disease and preventive care services. readmissions decreased 25%. total admissions decreased 15% and the total cost of medical care was 7% less than in our comparable medicare population. member satisfaction also improved on already high scores. next slide. in conclusion, we have learned that it is possible to deliver more value for our members, the business care for the model is strong. it was a 2-1 return on investment and the model has been rapidly scalability to practices of different sizes and types. we are currently in the process of designing and implementing a multipairer program in

northeast pennsylvania. case management is essential. they are both the resources of managing individual patients and act as a focus for our population management efforts within the practice. the partnership approach was important because it grew from the realization that neither the practice for the health plan can do this alone. both parties needed to be involved to be successful. electronic health records were helpful but not essential, we have used other tools to help practices without them achieve similar results. the most essential aspect of the model is to establish a time text that drives the practice to focus on delivering high value outcomes, individual patients and their populations. we have aligned the model with delivering these outcomes. in short, we found that if we give doctors a reason to deliver and pursue value for

their patients and we support their practices with data and operational enhancements, the care teams will deliver it and deliver it in the short term. thanks very much for the opportunity. >> this has been fascinating and i should have said at the beginning that what's great is that all of these experiments, projects, are well underway around the country and showing a lot of positive results but there has already been some activity in congress around trying to advance this effort, building on the things that you have been doing. so in the recovery act there was some funding for additional preventive health activities and product care management activities and in addition the house has a reform bill that three committees have put forward does have funding for pilots around doing more of this around the country that will be informed by the things

you all have done. it's not like we're just talking an academic circles here. this is already happening and congress is taking note and trying to move it forward. >> would you like to get discussion going before we -- >> great. >> do you want to just -- >> sure, i'll dive right in. i mean, based on what nancy was saying, i think one of the things that will be interesting to here from you is with these great examples and models that we have, how do we take that to a larger scale, to a national scale? what are the things we need to consider and the ways in which we can go about doing this? >> [inaudible] >> what we have seen is smir from 17 -- anywhere from 17% --

[inaudible] >> we firmly agree on a set of principals that we give to you as a gift, organized primary care, everybody around this table are doing the pilot following those principals and it's more than just client care management. it's more than just care coordination. it's comprehensive primary care for all of -- there is no other civilized nation on the face of the earth that have health care value without that foundational fundamental understanding of health care. my members and my patients want access. they want convenience. they want to be able to use tools like e-mails to communicate with their doctors and their doctors to be paid for that. that's fundamentally

foundational. the bills that you are talking about on the hill, we support them, but they focus narrowly on stuff like chronic disease. when you do that, you miss the whole point of the system that is designed for everybody. primary care for everybody, that's a foundation. >> let's try to catch it around counterclose-wise. >> i wanted to point out some things from the discussion, what can we do to really move this forward. first of all, health i.t. i think there is an opportunity with our measures that people use, things that are done currently at h.h.s. to signal to the h.r. industry that there is some standardized ways that these systems need to support. right now too many practices have to figure out on their own

how they can get this to work for them. so there is an opportunity for those. secondly, the idea the regional centers, but we have heard of lots on the table. the programs and call them centers to support them. and finally interactive. again, you can achieve a lot of coordination of care within an integrated system. it's really hard to achieve right now without the kind of interon per ability where systems can talk to each other. >> tim. >> i thank the presenters for providing the data. it's important for people to understand there is a lot more information out there other than medicare demonstrations. if you haven't published the data, i suggest you get it out

there and publish it. it's an important body of work. i focus on the functions and i heard some real common themes across the board here in terms of what are the key functions that really seem to be effective in driving these results. one was integration of the care coordination with the physician practice. we have learned that from the medicare demonstrations. we are also learned it from the work in north carolina, vermont , and some of the other models as well. that's essential. second is building in a transitional care component. this is critical in the medicare program where you have 20% of patients readmitted in 30 days. we heard the results. we can reduce those by 25 to 50% if you have a program put in there that is targeting those. targeting the right patients and measuring progress on that, also important, i think we learned that from how not to do that in the medicare demonstrations. we have seen the value of how to do it in these programs. the fourth piece would be population-based primary

prevention, disease aversion. we talk about prevention in terms of detecting disease, that's important. averting disease in the first place is as important and we have some proven results of how to do that. i think that's in a population base, a core part of what we do here. the role of data and measurement and evaluation, having that feedback component about how well we're doing in providing that information organically to the systems i think is critical as well. the final point i would make is payment reforms. i guess i'm thinking more specifically about fee-for-service medicare but making sure you align financial incentives and payment incentives with the structural changes i think is an important part. i would target those function yalts. if you target the functions we can scale this. we have seen this in vermont and north carolina. it's the direction to go. the congressional bills are on the right path. the issue is can we improve on those, can we keep pushing?

i hope so. i guess the pinal point is certainly what they put in those bills is better than what we're doing now. we're going in the right direction. there is a lot of lessons how to improve what we're doing in this current discussion. >> bob and then dan. >> i appreciate ken is going before me. he said half of my talk. >> is allows me to say something else. what ken is pointing out is very important that all of these groups have very common function yalts, very common vision and goals. actually they can learn from each other. that's fantastic. you have a model that is escapable, a model that is implementable. what i wanted to talk to you i'm the agency for health care research and quality has asked us to do evaluation of a primary care substantial-alone in texas. it is a variation in scalability that without payment reform, without

facilitation, without vision and getting there, without getting all of the payers involved, this goes from a two-year process in some states to a 15-year process. it takes some organization and some work to help practices get there particularly as craig was saying in areas where you have ones or two or three-person practices. you need to facilitate those people getting there and you need to help get the payment reform, the community care teams, the public health integration set up for them and get them involved in the process. that will take you from a two-year to a 15-year process or 15 to two-year depending how you set it up. >> thank you. >> i have five really quick thoughts. one is education, communication what this is and what it's not. i think that the american public would just be really excited to hear about what this is versus what it's not. i think one, communication, these type of sessions and

taking this out on a broader platform would certainly be helpful. common theme leadership, bring all of the governors together, share these stories and you hear a common theme about leadership. we get a chance to spend a lot of time with the state leaders and the governors are looking for ideas about this that would get a cost and quality. you could sponsor something to bring in these kind of ideas. third idea, incentives. we need to bring the health plans into this conversation. it's great that cigna is part of this conversation. the health plans can play an important role in creating the right kind of incentives. bring them in. if they want to come, bring them into this conversation. it's a healthy one. primary care education. we need to have a resurgence of primary care physicians. we need to look at the team care models. you hear about team management. start encouraging people to

build new medical schools that have primary care as a foundation. i think that would be very helpful. your voice heard that would go a long way. last but not least, encourage this level of incubation. find a way to continue to fund these kind of projects will it's rapid learning networks including whether formally care, whatever it might be. any monies you have to continue to drive this, we can shorten that 15 years to two years based on that experience. those are the five things, communication, leadership, incentives, primary care education and continue to find a way to fund these kinds of projects that are making a difference. >> john and chris. >> two more. >> again, congratulations and i think it's remarkable how the functions around primary care have all been satisfying in each of these projects. the first contact, continuous comprehensive and coordinated

care but also that everybody has held on to the key elements. updated as ken mentioned in the information management systems, a shared decision-making with patient's decision-making. those were key elements. what we need to think about more is think from a patient's point of view. it's one thing to have a patient experience through an integrated health system. it's another thing to have a patient experience through a series of silos from the practice to the hospital to wherever. so the state-based incentives such as allen and craig mentioned and susan compared to the integrated health systems, how we can turn this around and think that from a patient's point of view as they navigate their way through the health care system that they will expect and get the same quality of care and cost reductions

across a community of care as opposed to each individual silo of care. >> thanks so much. i just wanted to say very briefly, i think one of our goals is better coordinated care. we don't have the uninsured in the country. as you're looking at primary care, i urge you to look at the system that they have in richmond, virginia with the v.c.u. system coordinated care for the uninsured that give them a medical home, a primary care network. these are all people that do not have access to health insurance today. i know they're doing some of that in north carolina also. i think there is a couple of very good models out there for the uninsured right now. >> kevin is the only one we did not get to. >> i think i shock you. >> it's usually not the case. >> you must not be feeling well. >> i agree with all of the comments and again i appreciate everybody sharing their experiences. look, folks. i think there has got to be a vision there and i think partly, and you sort of laugh.

we talked about this before, it is a vision for what health care in this country should look like. it's getting beyond it's about coverage. we have to cover everyone in the country. it's the first start. we're not doing a good enough job. for the insured, it's good, but it's not great and it's not the level of superb care that everybody should be getting in this country. you hear pockets of where that's happening, where any one of us would like to go to group health or go there and say that's the care. we should be saying that's the care every american should be getting today. they should be getting accessible whole-person patient-centered care that is built on a solid foundation of primary care. that is not the governing ethos of this health care system right now. it's about how much high-tech can you poor into it, how much sub speciallation can you give, how many new hospitals can you build. that's the incentives from the

medicare, medicare, to the payment schedule to the investment in medical education. there has to be ownership and a willings of vision saying that is not buying us high quality patient-centered, accountable, sustainable health care. we need a new vision and the white house is willing to articulate a vision that is built around whole-person patient-centered care. the emergency in all this is the foundation is crumbling under our feet right now. we have half as many people going into physical medicine had general internal medicine as there were a decade ago. physical assistants, everybody model you have heard of is built on a foundation but core members with primary team members. if we don't reverse that trajectory write away, we won't have the capacity nation wide to achieve this vision. i would like to hear that articulated. i think the public would get that, that this is why every american has a stake in health care reform. it's a better type of care they

will be getting that works for them. i think we really need to look across the board of what we're going to do to rebuilt that foundation that undergirls the entire system. >> a great conclusion. i think you have heard that vision here today, kevin, and manifested what's going on around the country. i'm a glass half full person. i was thrilled to see that there was as much desem nation of this model as it is. i wasn't aware that group health was doing it and i didn't realize you were spreading it out so much. i have been to vermont and talked to governor douglas who is a great spokesperson for the cause, he does talk to other governors about it as well. i think that is what we're aspiring to here and just the work of everybody in this room, we can make it a reality.

>> i'm hopeful, too. there are really good elements in the bills moving forward. i think we need to assure that they stay there and are strength then the. >> we do. >> thanks, everyone. [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2009] >> president obama is on his way back to washington after wrapping up meeting in mexico.

topics at the north american leaders summit included trade and the world economy. you can see the closing news conference tonight at 8:00 eastern here on c-span. >> sunday, ellis, contributing editor and columnist for "newsweek" magazine on his public series. q & a sunday night at 8:00 on c-span. >> how is c-span funded? >> by donations. >> federal funds or grant funds. >> maybe some private contributings. >> honestly, i don't know. >> i would say from commercials. >> advertising. >> something from the government. >> how is c-span funded? 30 years ago, america's cable companies created c-span as a number service. a private business initiative, no government mandate, no government money.

>> a discussion now on israeli counterterrorism strategy. speaksers including the director of israel's counterterrorism bureau. this is about an hour half. >> good morning. my name is alexander and i'm the director of the interuniversity center for terrorism studies which is a consortium of universities and think tanks in almost all of the countries around the world. first let me work on obviously our speakers today. the general who is the director of the counterterrorism bureau,

the national security council and my colleagues professor william olson from the southeast asia of strategic studies and national defense university. my colleague, professor edgar brenner, he will introduce our speakers. i would like to also welcome the group, the audience which represents academics as well as government officials, member of embassies and the media. in particular, i would like to thank c-span for broadcasting this event as a public service to provide the discussions for consideration of the wider

audience in the united states and abroad. just two footnotes before professor brenner introduces our speakers and i would like to first mention since we do have an israeli general speak today that the evolution of the academic work between the united states and israel goes all the way back, i will say, at least in my limit experience four decades. the reason why i mention this because it was recognized obviously in israel back in 1967 after the war that perhaps the war would trigger it so we

developed academic programs in israel that the universities in cooperation with american universities such as the state university of new york and george washington university, georgetown center for strategic and international stud is and all of this. the -- studies and all of this. the reason that i mention this, that particular bridge built all the way back still existed and we do have a great deal of programs, academic programs with students and professors, conferences and publications and so on and so forth. i would like to mention particularly one event back in 1979, a conference in jerusalem that was initiated by benjamin

netanyahu who is now the prime minister and this was the first international conference we participated in that particular event and subsequently in the 1980's and 1990's, we developed a economic structures to deal with that particular challenge. first, the challenge to israel itself but then the globalization of terrorism worldwide. and in particular, i like to mention one of the reports that i'm sure we're going to discuss some of the aspects today is how to prevent superterrorism and we had at that time professor edward seller was our

chairman and another professor who was the foremost physicist in israel and tragically, of course, we would have to say today there was a nuclear challenge and some of our academic work was, as i mentioned before, published also in various books. one of them, benjamin netanyahu also participated in our work and we continued the relationships over many, many years. now on the substantive aspects in terms of a context for our discussion today, it seems to me that we do have to put the challenge in some sort of perspective. for example, as all of us know,

this week marks the 64th anniversary of the attack on nuclear issue. and i think one of the major challenges that we were left to deal with in our discussions today and in the coming weeks and months is the question of the nuclear program of iran. so the bottom line is -- will the international community, for example, allow iran to have a nuclear weapon in light of the fact that we were today, marking as i mentioned the nuclear experience. to put it differently, in terms of the context of our discussion, in terms of israel's strategy, the question

is will the almost century middle east conflict between israel and the arab world and the palestinians in particular will continue for the next 100 years? this is a big really question. and of course depends on the perception. for example, if we take one of the old middle east proverbs that the dream of the rise and war is the history of man. in other words, i'm sure that our speakers are going to fashion this and other relevant issues so i'm going to call on my colleague, professor edgar brenner, with whom we worked over the past 25 years at g.w.

and the international law salute and with israeli institutions, he is going to introduce our speakers. >> thank you, professor alexander. as the professor mentioned, brigadier general is currently the director of the counterterrorism bureau as israels national security council. during his period of active military service, he had important responsibilities on israel's northern front, israel's west bank, and the gaza strip. for a time, he was military ato say at the israeli embassy in washington, d.c. and he had responsibilities coordinating with the united states army, the united states navy, the united states marine corps and certain government departments. we welcome him here today. >> thank you very much.

i prefer to stand. >> fine. >> so i can see all the audience. first of all, good morning and thank you very much having me here. i'm very excited. i'll try in the next two minutes try to explain to you who we are, what we are doing and then for about another 25 minutes to share with you the main terrorism challenges as we see them in israel, and not only in israel, but all over the world. then let you ask as many questions as you want and hopefully i will be able to address them. the counterterrorism in bureau in israel is part of the embassy and actually i am a double head as the head of the counterterrorism bureau, i'm also the counterterrorism advisor for the prime minister and actually we gain our power from government or cabinet resolution. in any subject which we are

dealing with, and there are many, we have kind of a cabinet resolution that actually ordered us to take care of this issue and to make sure that we are a combined effort with all of the agencies or take direct responsibility to make sure that these issue is taken care of by someone or directly by ourselves. we do have something like eight or nine national direct responsibilities. for example, i'll let you get a better understanding what this is all about. the staff is very small. we are about 25 people, but because of our structure and all the agencies, all of them working with us and for us very

gently and i can say probably first time in the state of israel that when you succeed to leave the eagle outside of the room, you can get very good cooperation with everyone and that is our first rule. leave the eagle outside of the room. remember all the time that you are walking for the people of israel. you are working to provide them with better security and leave all the thing out so that you will get -- and actually what's happens, you have very good cooperation with all of the agencies which allows us to hopefully provide better security to our people in israel and outside israel and i'll give you a few example, how come that we have to take care about people from israel who are traveling abrord. -- abroad. i'll try to share with you our concern regarding the terrorism threats. i don't want to stay only in

academic statements or i'll try to give you as many examples as i can related to the israeli case so you will be able to connect between the main concept with the real life, daily life in israel trying to provide how do we deal with all of those potential threats. let me start by saying that for my point of view, in the terror arena, the last few years we can see the state's or nation assets supporting terror. this is something a little bit new for us and i can give an example. 10 years ago, if you had the chance to be part of a terror cell in the state of israel, you would see three, four young

guys sitting in the backyard of somewhere trying to create the booby traps with the very simple things, with the very low level of knowledge that can kill people, but it was a very simple device, very nonsophisticated. if you compare it today with those three young guys who decided to be a terror cell, you can see that they are supported by national assets, some of them through the web, some of them directly from states like syria, iran, and north korea. so speaking about national assets supporting terror, we have to at least raise three or four different national capabilities and i'll give you an example.

we all know that one had 22-millimeter rockets, something that can reach the range of 40 kilometers. this is probably capability that it's very rare to see in terror organizations. a year ago, we could see iranian efforts to take this large rocket, divide it into four different pieces so it will be much easier to smuggle them through the tunnels above the corridor, the border between gaza strip and egypt. this is an example of how you can take nation capabilities, use them to divide a large rocket into four different pieces so it will be easy to smuggle them and then put them together and then launch them

40 kilometers. this is one example. the second thing we have to think about is actually looks like civilians goodwill activities which is having student exchange all over the world. we can see today students from our area as well as from iran and other states going overseas to study in canada, australia, great britain and here in the united states, they study history and then during the year they're moving slowly into different type of study like chemistry, biology and gained a lot of knowledge regarding chemistry and other things that may be transferred very easily to use a terrorist. another example is using the

nation capability to fake -- we had a says that we succeed to monitor some members trying to launch an attack against the israeli embassy. .

and we all have to make sure that we have a list of national capabilities, national assets, that may be used by terror, and if you have this kind of list, at least you know what kiner f -- what kind of threat there are and how to avoid or be with those kinds of national assets or national capabilities supporting terror. last but not least, i would like to give an example regarding improvised explosive material. this is a great challenge for all of the security forces, and,

unfortunately, today, when you take those national assets or those professors, and i have nothing against professors, and those doctors, it is very easy for the terror organizations to get very sophisticated improvised explosive material which actually was produced by those national assets, national laboratories, and we do not have a full answer for that, because one of our main challenges regarding what the technology can support has to provide better security for all of us. the second issue that i would like to raise related to what if short story. if we had a chance to read a report written by the head of the global jihad, there is no

person like that, but let's assume there is a guy it somewhere sitting and has to write the report, -- there is a guy some were sitting and has to write the report. what are the lessons learned from all of the wide spectrum of activities that we have had in the last few years? i can share with you my thoughts that at the end of this report after he probably describes -- described that even though they succeeded to launch several attacks, the level of success is very poor. if we look into the past three or four or five years of global jihad activities, we probably see a very low level of success, so what is the results? what is the outcome of this

report? the outcome might be, and this is my personal assumption, that the next step, running by the global jihad, will be using the nonconventional terror. it is very easy to implement, unfortunately, creates a lot of damage, creates a lot of mess, can create a lot of economical problems. just think about los angeles port, describes that there is a container with a dirty bomb inside. then what? i can assure you that the level of damage is very low, but now, they have to shut down the port for two days, three days. can we measure the economic damage it? very large. so there is kind of what comes

first. all of the security forces all over the world trying to prevent and eliminate the global jihad capability may push them to use the nonconventional terror, and that pushed me back to the first point, if they really want to use the nonconventional terror, they may need some nation supports, and, again, it is well known. they can get it from iran. they can get it from syria. they can get is from north korea and others, and they can produce it by themselves those that know how with what exists on the web at any moment. if they can study something, from the last flu event that we all suffered from, they can very easily try to duplicate it.

i can speak about smallpox and something even less dramatic than smallpox. because if a person is willing to commit suicide, he can very easy willing to be sick. it is nonsense. he will be sick and distributed all over by coughing and by doing other activities, and just the economic damage, the more damage, and the other is that comes from this type of terror is a very large, and i will be frankly with you, we do not all have enough solutions for nonconventional terror. i have the responsibility to implement the yearly plan how to grow the national capability to be able to deal with nonconventional terror. without pushing my people into a

panic, allegany put some sensors -- how can you put some sense or is? let's assume you do have the right sensors. -- how can you put some sensors? they would just get into a panic. i am not saying that the threat is here tomorrow morning. i am saying that the threat of nonconventional terror exists and the global jihad is probably going into this direction, because otherwise, they will write another report five years from now that they did not succeed implementing the mission. i mentioned already about the web as a place of having a new type of terror, and i usually

use the example of a cia agent. if you had the chance to describe something, and the worries of the cia, two meters wide with muscles being able to do almost everything, so today, if you want to fight the radicalism, terrorism inside the web, you need a totally different person. you need a person that knows the koran. you need a person that can speak five or six different accents with arabic. you need a person who can simultaneously be with five different computers to make sure that he can recognize it places that the other guy from the other side -- he should be able to google very fast to find the name of the feature that the guy on the other side -- if he knows

it or not just to make sure he speaks with the right person. he has to be able to use the koran if necessary as a password from room to another room, so there is a global jihad or by that guy, and then that seagram with the bad terror attacks. and then that seagram -- seagram -- sea room. there is a joke in all the services that may be in one of those seagrams, there is a meeting between the cia agent, and all of those are meeting together in the same room, but they do not trust each other

that they're not the real global jihad fighters, and that would be the next step in implementing a terror attack, but that is only a joke. i know that here in the united states, they are dealing with these kinds of threats. again, this is another issue. people from the muslim world or the arab world are other places that are trying to attack our systems, and sometimes they

succeed to penetrate a civilian webb, which you never think is critical for you to defend it, but if this is the web, is they have to stay in the shelter, or the market is open for resupply, that becomes a crucial web for them, and therefore, they have to defend it. all of the civilian channels just to make sure -- even though it is the military or critical infrastructure. so those people who are living in this area, this is a very critical infrastructure, and it is my duty to defend it.

we also see the web today as a great place to recruit people. just lately, i have heard that the marine corps decided to use the marine web, facebook, and other things, even without putting attention, you provide information and provide other things to the other side. but i am speaking about using easier things to recruit people. we are all aware of the economic situation, so let's assume that there is a young guy in israel looking for a job, and he sends his c.v. somewhere to, one of the place is looking for someone with his skills, and somebody monitors it and invites him to interview.

a match between somebody who is looking for a job than someone who is using your position to cheat you or to kidnap you. those are totally new threats for everyone. those that want to gain more money do not leave israel and go to cyprus, for example, because on the other side of the room, there is a sleeping cell, trying to kill you, and taking new from cyprus to a two-hour drive elsewhere, and you will not have a clue that it has happened. those are new types of threats.

to see a soccer game and to do whatever we want to do as a people. the balance of the level of knowledge that you want to assure the public with you, and between let them live the good living, it is always a challenge that we as a people have to take care of. i would like to raise shortly some local points that may create is really challenges.

some that suffer from the same phenomenon. we face it in gaza strip and hamas, and i am actually speaking about an armed militia. actually, they do not have any responsibility. they hold the veto power without responsibility. i have to admit that after the first war in lebanon, the second

war in lebanon, the level is a little bit higher than it was a few years ago, but we all know it cannot hold forever. i am looking to supply things for my people. even the one level right now is a little better by, we still see, some members trying to launch a suicide attack. while we are sitting here, there are about 20 different terror cells but left the gaza slipped -- causes strep.

we declared a very loud and clear that the hon moss -- we would not tolerate was another wave of suicide bombers almost all over the world, trying to launch a payback.

what they want to launch an attack so having these two armed militias, hezbollah in lebanon, they have less responsibility both of them. bombers, launching rockets, kidnapping, you name it.

i am sure you're all aware of what happened in a village down in the southern part of lebanon. i want all of this to study this. make all of those villages in the south part of lebanon as a strong part. there is something that will force us to use of force against innocent civilians. if you take a picture of all of the villages, you will say --

seen -- see a lot of rocket launchers, etc.. unfortunately, this is the case right now. moving from the israeli side to allow them to implement their missions, the israeli forces are not playing the right game, if i can use that term.

the armed forces see the resistance as part of the capabilities, and he sends a dual message to his people. what should think the young captain in one of the platoon's station in part of lebanon when he has to cooperate to find hezbollah activities? this is the message coming from his commander. i can tell me for sure that he is very confused. how can he walk with unifil to eliminate hezbollah doing, but

we all have to do something. they have to make a decision. which side of the fence that they prefer to be, the hezbollah side versus the other side. with your permission, i would like to say a few words regarding smugglers weapons, no how, and money. i have told the egyptians, which, by the way, are doing a very good job recently, but without criticizing them, they're always steps where you can do more than you are doing

today. when i had a chance to speak with the egyptians, and i had many opportunities to do so, i tried to do not describe the situation. you never relied on the goalkeeper. the goalkeeper is the last to defend the mind. -- the line. it is not whether or not you are a good goal keeper. you need to fight against these phenomenon. the tb's phenomenon. it is well known that most of the smugglers are coming from the sudan. the distance of the egyptian border of sudan into the gaza strip is something like 1,000 kilometers. during this distance, you have to cross the suez canal, and you have only three bridges to cross the suez canal.

it is very easy to implement a checkpoint and to make sure that nothing penetrates the area of sinai. and by doing that, you can solve the problem, just like that. for many good and bad reasons, they just cannot create checkpoints where they want. when you are thinking about smuggling into the area of gaza strip, we are thinking about know how, people with a lot of experience, a lot of knowledge, coming from iran, syria, into the gaza strip area, and actually improve the capabilities and operate them almost any given area.

communication, explosive material, production, you name it. when you have someone who knows how to do that, all you have to do -- he will build it. we're thinking about the money issues coming into the gaza strip, a large number of everything. we know that hamas now is working very hard to reach the range of 75 kilometers rocket. he cannot do it by it himself.

if you duplicate the hamas capabilities, you'll see the whole state of israel covered by rockets. therefore, for us, it is very crucial to divide between gaza strip and other, but even if one day you have a town or a bridge between those two sides, we have to monitor the gates to make sure they are not moving from one side to the other.

and last, i want to say a few words about iran. iran is a state that supports terror from all aspects, know how, trading, money, equipment, you name it. i would like to be focused on the final issues. not only because of the nuclear program. they are supporting terror by financing.

they can show it anywhere that the iranian central bahn is part of the system. to declare the iranian central bank as a terror organization, then we can create large damage. maybe try to change something in their minds. unfortunately, in our area, a large stick, willing to use it. that way, people understand

things. i have to show you that sometimes that sometimes jumps like a rabbit, runs like a rabbit, and even looks like iraq, and you are sure it is a rabbit, it even looks like a rabbit -- even looks like a rabbit, the situation in our area is very much not. so sometimes, even though you have at least three measures, you can still be very skeptic and say based on the intel that i know, based on the situation right now in my area, it is

very, very shaky, and if you ask me, it is only a matter of time before we see a terror attack with lebanon. hopefully not, but the suicide bombers from no mas side or payback activities by hizbollah. at least in two cases we are not going to tolerate with our response. at the professional level, we all know and understand, and we have to be prepared at a given moment to take care of this long list of threats, this long list of potential threat on our

states. >> the intention was to hear from the discussant, and then have questions. is that all right with you? >> you are the commander. >> today's discussant is a professor of strategic studies at the national defense university. previously, he was chief of information management unit in the coalition provisional authority, and that means baghdad, iraq. he was also formerly staff director of the u.s. senate caucus on international narcotics control. he is the co-author of "gray area phenomenon, confronting the new world disorder." another position he had was

deputy assistant secretary of state in the bureau of international narcotics matters, and that was an important function of the state department. before joining the state department, he served as acting deputy -- and the department of defense, where his office had primary oversight of low intensity conflict and related policy. professor, we welcome you to our session. >> well, good morning. i will be somewhat brief. comments for the discussion that follows. i guess my first observation

would be that when we are talking about strategy, it is not the sum total of the tactics that we employ, but in theory, anyway, the purposes that we employ tactics. with policy or counterterror efforts, involving violence as the medium of exchange, the potential conflict between the tactical and short-term and the strategic and long-term. in practice however, the tactical and short-term almost always prevail and often conflict with the strategic and long-term goals of a strategy. there are inherent a psychological and systemic reasons for this.

in part because the tactical and balls that which is concrete and immediate and response to things which we know and many times which are also personally and institutionally of interest to us, and we tend to gravitate towards them, and, hence, there are practical. while the strategic and long term are abstract, and, therefore, quite generally in practical -- genuinely impractical. some work against our strategic interests. it is the challenge of policy to deal with this conflict and to try to reconcile the cognitive dissonance from the inevitable conflict. the challenge now versus not now. those things which have to be done as opposed to those things

which we think need to be done. the needs and concerns were always trump the long-term considerations. but in the long term, if the tactics we employ do not support the strategic goals that we have outlined, then the effort, in fact, undermines the intense, so part of the discussion, it seems to me, of where we might go is to talk about the conflict between strategy and tactics. in that environment, as a second quarter and, there is always the issue of learning lessons from experience. for example, it is not new that states have sponsored at various times terrorist actions. this is, in fact, a problem for a very long time. indeed, it was the most likely

participation of serbian intelligence services in the assassination of archduke ferdinand that led to the first world war, so it is not a new phenomenon. what is of interest more recently is not state sponsorship but the increasing role of non-state actors and organizations and the support of terrorist activities, particularly the growth of international criminal organizations that can provide the levels of financial support, false documents, and a whole host of other activities to terrorist organizations worldwide in growing relationships that we're beginning to see between these types of organizations, and so, as we think about the kinds of environments that we have to deal with, we have to realize this is a much more complex world that we are used to thinking of in terms of states being involved. and the third possible corner

and one often comes up in this context when you talk about solutions or responses is to turn to talk about which causes and the need to address the root causes of terrorism to talk about root causes. -- to turn to talk about root causes. to date, both israel and the united states have focus marilee on military actions against terrorism while neglecting its route causes. -- have focused merrily on military actions against terrorism while neglecting its root causes. an effective campaign to prevent terrorism must, therefore, treat the disease as well as the symptoms by addressing the political and social conditions that give rise to extremism and

violence, because palestinian terrorism is, in part, in response to the israeli occupation of the west bank and gaza. steps that make the situation hotter are unlikely to improve the security situation. even with unilateral israeli withdrawal from the occupied territories, it would not appease some islamic jihadists. a realistic realistic middle ground would be to pursue an aggressive police actions against the extremists. this is a fairly typical statement that you find. i am, however, not add due to a fan of try to solve root cause is not a particular fan of trying to solve -- i am not a

particular fan of trying to solve root causes, because which one are they? one is aspiration and nationalistic goals of the groups involved. another cause is revenge, a cycle of violence and counter violence, that has put two people against one another. one only has to think of the situation in the balkans that has gone on. i do not know how one addresses root causes when you have two groups that have historical reasons not to forget or to forgive. another root cause is justice, but whose justice are talking about, and who is best to provide it? in some cases, root causes have on bounded goals. for example, in this particular

context, and unbounded goal is the elimination of the state of israel. if the root cause has to be addressed, and that cause has to deal with the annihilation of israel, that is a nonstarter. the other thing i have heard about the question of occupation. in many western mines, the problem in the confrontation between israel and the palestinians is the issue involved in the occupation of the west bank and gossip. well enough, but with a slight shift in perspective, the perspective from hamas or hezbollah, the occupation that is involved there is the existence of the state of israel itself, and they are the occupying power. jfbut of palestine, and the only solution for that is its elimination, so if that is the root cause, i am not sure how one begins to address that.

so the environment is not a simple and straightforward one, whether we're talking about a strategic approach for talking about tactics, but we will turnover for questions. >> all right, we will entertain questions now, but a short word on the logistics. is there somebody in the back with a floating microphone? good. when you are recognized, wait for the microphone to get to you, and then please identify yourself. that will help us make a transcript of these proceedings, which will be available before too long. i am also advised that the microphones on this front table will not pick up responses during questions and answers. therefore, i will ask the speakers when they responded to a question or comment to use the lectern and the microphone at the lectern. and that should handle everything very well. who would like to start? this gentleman here.

>> my name is -- i am from wrc. the question to the panel. as you know, these are reports about differences between the united states and israel. how do you look at the threats, and about iran? so my question is to the panel, do you see this difference, and what aspects are more important? when it is your estimate of it going to end? >> general, do you want to start with that? >> as far as we can think about the threat here, i do not think

there are big differences between the united states or other nations look at the military nuclear threat in iran. the problem big debate is what is the solution and what is the timetable that may force us to take some action. i do not think that today we have a different view regarding the iranian military. we have in the past. we were the first to say 10 years ago that there is a military nuclear program, and in those days, we were probably the only one that raised that issue. so i do not think that there is a really huge gap between the assessment of what is going on right now in iran.

there is the best solution and what is the timetable. we consider the timetable a point which allows that the iranians will use their nuclear know-how for military options, and from our point of view, maybe one year or one and a half years. >> would you like to comment? we are ready for another. >> no solution. [laughter] >> over here on the left. >> al milliken. have you noticed any changes in the way that women and children have been utilized in terror attacks, and is there islam

justification from the koran or elsewhere that promotes this as part of jihadists? -- jihad? >> it seems very easy questions, but before attacking the specific question, i have to say to all of us that we may not know enough and probably do understand deeply enough been some of the muslim world, and, therefore, we judge some of their activities in our western eyes instead of looking into the radical moslem way of thinking. i am not try to say that all of the muslims are bad. this is not the situation, and i

am not try to say that the muslim culture or the muslim religious is bad. one of them is the question that you just raised. the women and kids as part of the terror at efforts -- the terror efforts is everywhere, and, fortunately, there are enough imam that accepted -- and, unfortunately. there are enough leaders that accept it and encourage it, and this is something that we can all not understand. but let me share with you something that just finished recently. we had the chance to interview 21 terrorists that committed suicide.

there were technical problems. the captured than minutes before suicide. we found out that when you look into the family issues related to the person who commits suicide, the mothers are the key point, and they have the main power to prevent the sun from committing suicide -- the son from committing suicide, but our image from the media is that the muslim mothers are happy when their sons commit suicide. we had one woman in israel who had two kids who committed suicide. she became a member of

parliament with hamas. she became a hero. this is the image, but when you have the chance to speak with her one on one an interview her, you can see that like every mother on earth, she does care about her kids. our mission, our challenge, is to make sure that those radical imams will not lead the moslem way of thinking while they are fighting terror, because the level of using kids and women is very high. >> dr. olson? >> recently, we came across some

training camps, liberated them, whatever. to find that there were people in there as young as nine in 10 years old who had been recruited to be potential suicide bombers. so the exploitation of children and others, also the weak minded. you find out that they are using people where, even if they were adults, they are not able to give will recall informed consent, and that is a knowledge of the consequences about what they are recruited to do. that is what is happening. but there is nothing new about society or people using young people for these kinds of purposes. it goes back forever.

or for mothers who willingly and happily send their offspring off to die if they think the cause is justified and that the method is necessary. spartan mothers used to basically give their sons to the state and say, "if you are going to go off to war, come back on your shields or carrying them grow in other words, be victorious or die. -- or carrying them." in other words, the victorious or die. -- the victorious or die. islam contemns this very behavior out right. it does not justify it -- islam condemns this very behavior out right -- outright. the reason they may want to resort to violence, people will

seek justification for that in a variety of different ways, and what the islam ooh-rah is coming to grips with is the fact that the religion forbids it, but people are doing it, and the question then is how to come to grips with that, and slowly but surely, islam a public opinion is moving in the opposite direction than the groups like al qaeda and others are taking, and, hopefully, al qaeda and others are, in fact, in opposition to the very people they claim to represent, which is one of the reasons why most of the victims of islam, quote, islamic terror are muslims. >> professor? >> general nouriel spoke about the targets, the potential target, israelis, travelers, and

so on, and he also said that he has to focus on the potential terrorist, in other words, the source. the source is much larger. it is a much bigger problem. now, professor olsen added a third thing, and that is the cause, and i wondered to what extent you work on the cause, as well? >> busy enough to deal with the target and the potential -- probably do not have enough time to do with the cause, but a

little bit. i think it was great opening remarks by the professor trying to elaborate what are the causes for terror and also the different causes, and i could speak about the is really story. i am sure that if we have a chance to put the next to someone from the gaza strip, he will probably speak about the cause from the palestinian point of view, everyone has his own experience, and when we have to deal with because of terror in our area, we have to go back into the reality to be able to inform people related on fact,

not on the images and not only wishes. 2002, when arafat decided to launch the second, it was the best time ever from the economical point of view. those are numbers, not images. in october, 2010, better quality of life ever, versus the time they were under another regime, any given moment since the captured those. so when they think about the economical situation as a cause for terror, at least in this case, i can assure you that we have to consider it once again. when we are speaking about the occupation, having something to

say, probably my own opinion regarding the disengagement for gaza. but about the idea, probably more about the way we do it. people criticize us, why we did not coordinate. arafat left already. they had probably something like eight months. you need two to tango. and he decided he did not want to coordinate it. for his own reasons. again, i can share with you -- including areas that we can show everyone -- as part of the land

that we have. going back to june 1967. what was the outcome of it? once again, speaking about the occupation, what? i had the privilege for those three years to plan it and command it. the deputy division command. during the night without permission. but we left lebanon. does this change hezbollah

sinking even for 1 inch? the answer is no. there is a syrian village. now they have raised the issue, and there is a long list of things. because of terror related to the question. to accept us in the middle east. therefore, for us, for us, and sometimes when i have to explain it to people from europe, they cannot understand us.

to remain a jewish state, it is a crucial issue. it is not something that came from the bible is a simple request to live. this month, i am going to be 50. i have faced since the age of 15 almost four wars, many operations during the night without permission, almost everywhere. my simple request is being able to raise my kids. i can tell you my story, and this is my story. i can tell you that many of the israelis can accept the offer it

to arafat in 2000 as well as the offer by mr. ehud olmert one year ago. we understand that we have to leave the area of the west bank, and we cannot do as we did in cause a strip. the question is, and this is related to some politics, and i am trying to avoid getting into politics. to the settlements of the real problems between us -- let's assume that we have the magic words that can take all the settlements -- with one day, just like that, i studied -- candice of the problem between hamas and the